The Commonwealth of Massachusetts Department of Industrial Accidents Department 121 Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111 - 1750 Info. Line (800) 323 - 3249 Inside Mass. / (857) 321 - 7470 Outside Mass. www.mass.gov/dia APPEAL OF CONFERENCE PROCEEDING DIA Board # (If Known): FORM 121 Form 121 - Revised 7/2019 - Reproduce as needed. *Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents. Please Print Clearly or Type. Unreadable forms will be returned.1. Case Appealed By: Employee Insurer Other(Specify) 2. Medical Issue (Check one only) : Appeal fee attached Appeal fee to be submitted to Department 121 Form 136, Waiver Request due to Indigence filed with Commissioner Enlarge time frame to submit fee filed with Director - 3. Non - Medical Issue: 4. Date of Order (mm/dd/yyyy): 14. Date Prepared (mm/dd/yyyy): 6. Date of Injury (mm/dd/yyyy): 5. Name of Judge Who Issued Order: 10. Name, Address & Telephone # of Attorney: 11. Name, Address & Telephone # of Attorney: Please Print or Type INSTRUCTIONS ON THE REVERSE SIDE 7A. Social Security Number*:American LegalNet, Inc. www.FormsWorkFlow.com APPEAL OF A CONFERENCE ORDER FILING INSTRUCTIONS 1. PURPOSE: To file an appeal of a Conference proceeding pursuant to Massachusetts General Laws c. 152, 247 10A 2. WHEN TO FILE: An appeal must be filed within 14 days from the filing date of an administrative NOT to be used to appeal a hearing decision of an administrative judge. 3. WHERE TO FILE: Department of Industrial Accidents Lafayette City Center 2 Avenue de Lafayette Department 121 Boston, MA 02111 - 1750 Copies of this form must be mailed to all interested parties. 4. IMPARTIAL MEDICAL EXAMINATION FEES: Submit fee within 10 days of the appeal pursuant to M.G.L. c 152, 247 11A (2) to Department 121 or submit Form 136 Waiver Request based on 5. Separate appeal form should be submitted for each board number. 7. NOTICE: Failure to file a timely appeal shall be deemed to be acceptance of the administrative 247 10A). American LegalNet, Inc. www.FormsWorkFlow.com