Free 117 - Massachusetts

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FORM 117

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 FOR INJURIES OCCURRING ON OR AFTER NOV. 1, 1986

Page 1 of 2 Please Print or Type

EMPLOYEE _______________________________ LUMP SUM AMOUNT $______________________ EMPLOYER _______________________________ TOTAL DEDUCTIONS $______________________ INSURER _________________________________ NET TO CLAIMANT $______________________ BOARD NUMBER _________________________ TOTAL PAYMENTS DATE OF INJURY__________________________ CHECK WHERE APPLICABLE ( )
Liability has been established by acceptance or by standing decision of the Board, the Reviewing Board, or a court of the Commonwealth and this settlement shall not redeem liability for the payment of medical benefits and vocational rehabilitation benefits with respect to such injury.

$______________________
(Weekly benefits plus lump sum)

(

)

Liability has NOT been established by standing decision of the Board, the Reviewing Board, or a court of the Commonwealth and this settlement shall redeem liability for the payment of medical benefits and vocational rehabilitation benefits with respect to such injury. In addition to the lump-sum, the insurer agrees to pay all outstanding reasonable and related medical bills incurred as of this date. The employee is currently receiving a cost-of-living adjustment.

( ) ( )

DEDUCTIONS: From the lump-sum amount as stated above, the amount(s) listed below will be deducted and paid directly to the following parties: NAME ADDRESS 1. $_____________________
Attorney's Fee

________________________________________ ________________________________________
(Please attach documentation)

________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________
Form 117 - Revised 8/2001 - Reproduce as needed.

2. $_____________________
Attorney's Expenses

3. $_____________________
Liens Inchoate Rights

________________________________________
(Please attach discharges) (Please specify release)

4. $_____________________ ________________________________________ 5. $_____________________ 6. $_____________________ 7. $_____________________ ________________________________________ ________________________________________ ________________________________________ (OVER)

AGREEMENT FOR REDEEMING LIABILITY BY LUMP SUM SETTLEMENT EMPLOYEE MEDICAL INFORMATION: Age ______ No. of Dependents _____

(Page 2 of 2)

Average Weekly Wage $______________ Compensation Rate $_________________

Social Security No.*: ______-____-_____ Occupation _______________________ Educational Background _______________ On Social Security: YES ( ) NO ( ) YES ( ) NO ( )

On Public Employee Disability Retirement:

DIAGNOSIS ___________________________________ PRESENT MEDICAL CONDITION _________________________ ______________________________________________ Present Work Capacity: ______________________________ ________________________ Third Party Action _____________________________

PLEASE GIVE A BRIEF HISTORY OF THE CASE AND INDICATE WHY THE SETTLEMENT IS IN THE EMPLOYEE'S BEST INTEREST (Specify all allocations):

(Please attach a separate sheet if necessary.)
Received of ____________________________________________________________ the Lump Sum of _____________________________ ____________________________________ dollars and ________________ cents ($___________________) This payment is received in redemption of the liability of 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 _________________________________________________

____________________________________________. I fully understand that after all of the deductions herein I will receive $______________________________. I am fully satisfied with and request approval of this settlement. This agreement has been translated for me into my native language of _____________________________________.

SIGNATURE CLAIMANT: CLAIMANT'S COUNSEL: INSURER'S COUNSEL:

ADDRESS

ZIP CODE

Signed this _____________________ day of __________________________________ 20____
*Disclosure of Social Security Number is Voluntary. It will aid in the processing of this document.