Agreement Under Section 37 Or 37A Form. This is a Massachusetts form and can be use in Workers Comp.
Tags: Agreement Under Section 37 Or 37A, 123, Massachusetts Workers Comp,
The Commonwealth of Massachusetts Department of Industrial Accidents – Department 123 FORM 123 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 UNDER SECTION 37 or 37A DIA BOARD NO. §37 or §37A Claim Please print or type Please Note – For Injuries on or after 12/23/1991, the insurer must file their quarterly request for reimbursement within two (2) years from the date of the final approval of the Form 123. All subsequent quarterly request for reimbursements must be received by the DIA within two (2) years from the date of payment by the insurer. 1. Employee’s Name (Last, First, MI): E M P L O Y E E I N S U R E R 2. Home Address (No. & Street, City, State, Zip Code): 3. Employer’s Name: 4. Employer’s Address (No. & Street, City, State, Zip Code): 5. Insurance Carrier’s Name: 6. Insurance Company Address: 7. Name & Address of Person Able to Verify Information: 8. Telephone Number: 9. Paid Through (mm/dd/yyyy): 10. First Date of Disability (mm/dd/yyyy): 12. Total Amount to be reimbursed under Section 37 or 37A 11. If Employee Died, Enter Date of Death: : $___________________ (Check all that apply to this agreement) NEGOTIATED FULL & FINAL 13. Amount of Quarterly Reimbursements (if any): $________________________ 14. Is employee still receiving weekly compensation benefits? TYPE OF WEEKLY COMPENSATION Yes No If Yes, please fill out the following COMPENSATION AMOUNT a. Total Disability – Temporary (§34) $______________________________ b. Total Disability – Permanent (§34A) $_____________________________ _ c. Partial Disability (§35) d. Dependent Coverage (§35A) $______________________________ $______________________________ e. Surviving Dependents Coverage (§31) $______________________________ f. Other (Specify) ______________________ $______________________________ I hereby certify that the information contained herein is a true accounting of all payments made to the above named employee. ________________________________________________________________ Signature of Insurer’s Authorized Representative ________________________ Prepared Date (mm/dd/yyyy) _________________________________________________________________________________________ Name & title (Last, First, MI) I hereby agree to and approve the following reimbursement to be made per the provisions of this agreement. _______________________________________ __________________ _____________________________________________ Signature for the Office of Legal Counsel Date (mm/dd/yyyy) Name & title (Last, First, MI) I hereby agree to and authorize the following reimbursement to be made per the provisions of this agreement. _______________________________________ __________________ Signature for the Office of the Commissioner Date (mm/dd/yyyy) Reproduce as needed. _____________________________________________ Name & title (Last, First, MI) American LegalNet, Inc. www.FormsWorkFlow.com Form 123 - Revised 7/2010