Consent To The Payment Of Lump Sum Settlement
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Consent To The Payment Of Lump Sum Settlement Form. This is a Massachusetts form and can be use in Workers Comp.
Loading PDF...
Tags: Consent To The Payment Of Lump Sum Settlement, 116A, Massachusetts Workers Comp,
FORM 116A
The Commonwealth of Massachusetts
Department of Industrial Accidents – Department 116A
DIA Board #
(If Known):
600 Washington Street – 7th Floor, Boston, Massachusetts 02111
Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470
http://www.mass.gov/dia
CONSENT OF EMPLOYER
TO LUMP SUM SETTLEMENT
I,____________________________, sole proprietor/partner/corporate officer
of ____________________________________________________________
(business name)
located at ______________________________________________________
(address)
_______________________________,_______________________________
(city)
(state)
and experience-modified insured of__________________________________
(workers’ comp. insurance carrier)
hereby consent to payment of a lump sum settlement in the gross amount of
$__________________________________ in workers’ compensation in the
case of _____________________________ . The terms of such settlement are
more fully set forth in the attached lump sum agreement.
Signed this ____________________ day of _____________________, 20__ ,
pursuant to the provisions of Section 48 of Chapter 152 of the General Laws
of Massachusetts as most recently amended by Section 74 of Chapter 398 of
the Acts of 1991.
_______________________________
(signature)
Reproduce as needed.
Form 116A Revised 8/2001
American LegalNet, Inc.
www.USCourtForms.com
