The Commonwealth of Massachusetts Department of Industrial Accidents Department 124A 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 NOTIFICATION OF ARBITRATION AWARD DIA Board # (If Known): FORM 124A Form 124A - 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. ) : 17. Date Prepared (mm/dd/yyyy): ATTACH COPIES OF ARBITRATION AWARD TO THIS FORM. SEND COPIES TO ALL PARTIES American LegalNet, Inc. www.FormsWorkFlow.com