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FORM 117A

The Commonwealth of Massachusetts Department of Industrial Accidents
600 Washington Street ­ 7th Floor, Boston, Massachusetts 02111 Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470 http://www.mass.gov/dia

DIA Board # (If Known):

AGREEMENT FOR REDEEMING LIABILITY BY LUMP SUM UNDER G.L. CH. 152, SEC. 48 FOR INJURIES OCCURRING BEFORE NOV. 1, 1986

Page 1 of 2 Please Print or Type

Board Number ______________________________________ Employee _____________________________________________________ Insurer Or Self-insurer ________________________________ Employer _____________________________________________________ Insurer's Address ___________________________________________________________________________________________________

LUMP SUM AMOUNT $________________________________________________________________________________
Total Deductions $___________________________________ Total Payments $___________________________________ Net to Claimant $_______________________________________________ Insurer's Claim Number _________________________________________

Received of _________________________________________ the Lump Sum of _______________________________________________ ____________________________________ dollars and ________________ cents ($___________________) making with weekly payments already received by me , the total sum of ________________ dollars and __________________ cents ($_____________). Said payments are received in redemption of the liability for all weekly payments now or in the future due me under the Workers' Compensation Act, for all injuries received by_____________________________________________________________________________ on or about ____________________________________ while in the employ of _________________________________________________ subject to the approval of the Department of Industrial Accidents.

_________________________________________
Claimant's Signature

_________________________________________
Witness's Signature

_________________________________________
Claimant's Address

_________________________________________
Witness's Address

_________________________________________ _________________________________________
Signature of Insurer's Rep.

_________________________________________ _________________________________________
Date of Agreement

_____________________________________________________________________________________________________________________________________________________________________________________________________________

STRIKE OUT IF NOT APPLICABLE
I understand that from the LUMP SUM amount stated above, the amounts listed below will be deducted and paid to the following parties: 1. $_____________________
Attorney's Fee

________________________________________
Name

________________________________________
Address

2. $_____________________
Liens

________________________________________ ________________________________________

________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________

3. $_____________________

4. $_____________________ ________________________________________ 5. $_____________________ 6. $_____________________ 7. $_____________________ ________________________________________ ________________________________________ ________________________________________

______________________________________________________________________________________
STRIKE OUT IF NOT APPLICABLE
I understand that, in addition to the LUMP SUM amount stated above, the insurer or self-insurer will pay all outstanding reasonable medical bills incurred as of this date:

I understand that after all of the above deductions, including attorneys fees and other liens, I will receive the net amount of $_________________. I further understand that this is a complete and final settlement of my claim and that I will not be able to reopen my claim or seek further benefits because of this injury. I am fully satisfied with this settlement.

Claimant's Signature and Date

(over)

Witness's Signature and Date

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Employee:

Age: ______ Average Weekly Wage: ________________ Dependents: ______ Comp. Rate: ________ Social Security No.*: _________________________ On Social Security Disability: Yes ___ No ___ Occupation: ________________________________ If yes, from what date?: ____________________

Injury:

Nature: _____________________________________________________________________________ Place and Date of all injuries included ____________________________________________________ ___________________________________________________________________________________ Cause:______________________________________________________________________________

Liability:

Accepted: Yes____

No ____ If No, state reason __________________________________________

____________________________________________________________________________________ ____________________________________________________________________________________ If accepted, what is pending issue:________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Medical:

Original Diagnosis: ___________________________________________________________________ ____________________________________________________________________________________ Present Medical Condition: _____________________________________________________________ Present Work Capacity: ________________________________________________________________ ____________________________________________________________________________________

PERTINENT MEDICAL REPORTS AND BILLS SHOULD BE ATTACHED HERETO
COMPENSATION PAID: §34 $_____________ §35 $_____________ §35A $_____________ §36 $_____________ §34A $_____________ §31 $_____________

PLEASE GIVE A BRIEF HISTORY OF THE CASE AND INDICATE WHY THE SETTLEMENT IS IN THE EMPLOYEE'S BEST INTEREST (Specify any requested allocation of claimant's net amount):

Signatures:

Counsel for Insurer

Counsel for Employee
Form 117A - Revised 8/2001 - Reproduce as needed.

*Disclosure of Social Security Number is Voluntary. It will aid in the processing of this document.