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FORM 121A

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

AGREEMENT THAT NO IMPARTIAL PHYSICIAN REPORT IS REQUIRED
THIS FORM MUST BE SUBMITTED TO THE ADMINISTRATIVE JUDGE IN A TIMELY FASHION.

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EMPLOYEE _______________________________

BOARD NUMBER _____________________

Pursuant to 452 C.M.R. 1.10 the parties make the following agreement under the subsection identified below: (5) (5) (6) (7) ______ ______ ______ ______ The disputed matter concerns a §7A and/or death case. Dispute over entitlements of prior disability benefits. Agreement upon partial disability and causal relationship. Agreement that initial liability has not been established.

PARTIES:

________________________________ ________________________________

_________________________________ _________________________________

Pursuant to 452 C.M.R. 1.11(1)(d) at the discretion of the administrative judge at the hearing, the parties have been allowed to make the agreements indicated above. ADMINISTRATIVE JUDGE ________________________________________________

----------------------------------------------- FOR INTERNAL USE ONLY ------------------------------------------Impartial Exam Date _______________ Docketing Unit Impartial Unit Fee Date ______________________

Processed By ________________________________ Date _________________ Processed By ________________________________ Date _________________

Reproduced as needed.

Form 121A - Revised 8/2001