Addendum To Lump Sum Settlement Agreement Form. This is a Massachusetts form and can be use in Workers Comp.
Tags: Addendum To Lump Sum Settlement Agreement, 116B, Massachusetts Workers Comp,
FORM 116B The Commonwealth of Massachusetts Department of Industrial Accidents Department 116B 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 DIA Board # (If Known): ADDENDUM TO LUMP SUM SETTLEMENT AGREEMENT PURSUANT TO M.G.L. c. 398 247 75 OF THE ACTS OF 1991, EFFECTIVE DECEMBER 23, 1991 - VOCATIONAL REHABILITATION STATUS Employee Name: Board #: PART A Written consent of the Office of Education and Vocational Rehabilitation is not required as a condition precedent to the validity of the Lump Sum Agreement where: PLEASE CHECK ONE: Rehabilitation pursuant to G.L. c. 152, 247 30G. The employee has been found unsuitable by the Office of Education and Vocational Rehabilitation for Vocational Rehabilitation pursuant to G.L. c. 152, 247 30G. The employee has returned to continuous employment for a period of six months or more. The employee has completed an approved rehabilitation plan. Signed this day of 20. SIGNATURE ADDRESS CLAIMANT PART B Where the employee has been found suitable for Vocational Rehabilitation services pursuant to G . L . c . 152 , 247 30 G and has not returned to continuous employment for a period of six or more months or completed an approved rehabilitation plan, the Office of Education and Vocational Rehabilitation may nevertheless consent in writing to the Lump Sum, or an administrative judge or administrative law judge, by order or decision may authorize such agreement . G . L . c . 152 , 247 48 ( 3 ) . employee who receives a [lump sum] amount in violation of [ 247 48 ( 3 )] shall have the right to re - open his or her claim for compensation . Id . PART C Please note that when liability is established, the Lump Sum Agreement shall not redeem liability for the payment of medical benefits or vocational rehabilitation benefits with respect to such injury . An employee may seek vocational rehabilitation within two ( 2 ) years of perfection of the lump sum settlement . G . L . c . 152 , 247 48 ( 2 ) . Consented to : Date : Office of Education and Vocational Rehabilitation OEVR Comments: Order/Decision : Administrative Judge/Administrative Law Judge Reproduce as needed . FORM 116 B Revised 7 / 2019 American LegalNet, Inc. www.FormsWorkFlow.com