Appeal Of Conference Proceeding
Appeal Of Conference Proceeding Form. This is a Massachusetts form and can be use in Workers Comp.
Tags: Appeal Of Conference Proceeding, 121, Massachusetts Workers Comp,
FORM 121 The Commonwealth of Massachusetts Department of Industrial Accidents – Department 121 DIA Board # (If Known): 1 Congress Street, Suite 100, Boston Massachusetts 02114-2017 Info. Line 800-323-3249 ext. 7470 in Mass. Outside Mass. - 617-727-4900 ext. 7470 http://www.mass.gov/dia APPEAL OF CONFERENCE PROCEEDING A COPY OF THE ADMINISTRATIVE JUDGE’S ORDER SHOULD BE ATTACHED TO THIS APPEAL. Please Print or Type INSTRUCTIONS ON THE REVERSE SIDE 1. Case Appealed By: Employee Insurer Other(Specify) 2. Medical Issue (Check one only): 3. Non-Medical Issue: Appeal fee attached Appeal fee to be submitted to Department 121 Form 136, Waiver request due to Indigence filed with Director Enlarge time frame to submit fee filed with Director 4. Date of Order (mm/dd/yyyy): 5. Name of Judge Who Issued Order: 7. Employee’s Name & Address (No. and Street, City, State, Zip Code): 6. Date of Injury (mm/dd/yyyy): 7A. Social Security Number*: 8. Employer’s Name & Address (No. and Street, City, State, Zip Code): 9. Insurance Carrier’s Name & Address (No. and Street, City, State, Zip Code): 10. Name, Address & Telephone # of Insurer’s Attorney: 11. Name, Address & Telephone # of Employee’s Attorney: 12. Preparer’s Name, Address (No. and Street, City, State, Zip Code) and Telephone #: 13. Preparer’s Signature (“On-File” is NOT acceptable. Must have signature.): 14. Date Prepared (mm/dd/yyyy): 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. Form 121 - Revised 8/2015 - Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com APPEAL OF A CONFERENCE ORDER FILING INSTRUCTIONS 1. PURPOSE: To file an appeal of a Conference proceeding pursuant to Massachusetts General Laws c. 152, Section 10A 2. WHEN TO FILE: An appeal must be filed within 14 days from the filing date of an administrative judge’s conference order. This form is NOT to be used to appeal a hearing decision of an administrative judge. 3. WHERE TO FILE: Department of Industrial Accidents 1 Congress Street, Suite 100 Department 121 Boston, MA 02114-2017 Copies of this form must be mailed to all interested parties. 4. IMPARTIAL MEDICAL EXAMINATION FEES: Submit fee within 10 days of the appeal pursuant to M.G.L. c 152, Sec. 11A (2) to Department 121 or submit Form 136 Waiver Request based on Indigence to the Director’s Office. 5. Separate appeal form should be submitted for each board number. 6. NOTICE: Failure to file a timely appeal shall be deemed to be acceptance of the administrative judge’s order and findings (M.G.L. c. 152, Section 10A). American LegalNet, Inc. www.FormsWorkFlow.com