AGREEMENT UNDER SECTION 37 or 37A 12. Total Amount to be reimbursed under Section 37 or 37A : $ 14. Is employee still receiving weekly compensation benefits? Yes No If Yes, please fill out the following TYPE OF WEEKLY COMPENSATION COMPENSATION AMOUNT I hereby certify that the information contained herein is a true accounting of all payments made to the above named employee. 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) DIA BOARD NO. 247 37 or 247 37A Claim a. Total Disability Temporary ( 247 34) $ b. Total Disability Permanent ( 247 34A) $ c. Partial Disability ( 247 35) $ d. Dependent Coverage ( 247 35A) $ e. Surviving Dependents Coverage ( 247 31) $ f. Other (Specify) $ 9. Paid Through (mm/dd/yyyy): 11. If Employee Died, Enter Date of Death: Form 123 - Revised 7/2019 2. Home Address (No. & Street, City, State, Zip Code ): 6. Insurance Company Address: 7. Name & Address of Person Able to Verify Information: 8. Telephone Number: E M P L O Y E E 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) Name & title (Last, First, MI) FORM 123 The Commonwealth of Massachusetts Department of Industrial Accidents Department 123 Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111 - 1750 Info. Line (800) 323 - 3249 in Mass. / (857) 321 - 7470 Outside Mass. www.mass.gov/dia 10. First Date of Disability (mm/dd/yyyy): I N S U R E R NEGOTIATED FULL & FINAL 13. Amount of Quarterly Reimbursements (if any): $ (Check all that apply to this agreement) Reproduce as needed. 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 . American LegalNet, Inc. www.FormsWorkFlow.com