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Agreement For Redeeming Liability By Lump Sum - For Injuries On Or After 11-1-86 Form. This is a Massachusetts form and can be use in Workers Comp.
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Tags: Agreement For Redeeming Liability By Lump Sum - For Injuries On Or After 11-1-86, 117, Massachusetts Workers Comp,
FORM 117
The Commonwealth of Massachusetts
Department of Industrial Accidents
DIA Board #
(If Known):
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470
http://www.mass.gov/dia
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
$______________________
(Weekly benefits plus lump sum)
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.
( ) 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
2. $_____________________ ________________________________________
Attorney’s Expenses
3. $_____________________ ________________________________________
Liens
________________________________________
(Please attach discharges)
4. $_____________________ ________________________________________
Inchoate Rights
________________________________________
(Please attach documentation)
________________________________________
(Please specify release)
5. $_____________________ ________________________________________
________________________________________
6. $_____________________ ________________________________________
________________________________________
7. $_____________________ ________________________________________
________________________________________
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(OVER)
Form 117 – Revised 7/2010 - Reproduce as needed.
AGREEMENT FOR REDEEMING LIABILITY BY LUMP SUM SETTLEMENT
(Page 2 of 2)
EMPLOYEE MEDICAL INFORMATION:
Age ______ No. of Dependents _____ Average Weekly Wage $______________ Compensation Rate $_________________
Social Security No.*: ______-____-_____ Occupation _______________________ Educational Background _______________
On Social Security: YES ( ) NO (
)
On Public Employee Disability Retirement:
YES ( ) NO (
)
DIAGNOSIS ___________________________________ PRESENT MEDICAL CONDITION _________________________
______________________________________________
Present Work Capacity: ______________________________
________________________
Third Party Action _____________________________
PLEASE GIVE A BRIEF HISTORY OF THE CASE AND INDICATE WHY THE SETTLEMENT IS
IN THE EMPLOYEE’S BEST INTEREST (Specify all allocations):
(Please attach a separate sheet if necessary.)
Received of ____________________________________________________________ the Lump Sum of _____________________________
____________________________________ dollars and ________________ cents ($___________________)
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
ADDRESS
ZIP CODE
CLAIMANT:
CLAIMANT’S
COUNSEL:
INSURER’S
COUNSEL:
Signed this _____________________ day of __________________________________ 20____
*Disclosure of Social Security Number is Voluntary. It will aid in the processing of this document.
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