Employees Hearing Memorandum
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Employees Hearing Memorandum Form. This is a Massachusetts form and can be use in Workers Comp.
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Tags: Employees Hearing Memorandum, 161, Massachusetts Workers Comp,
HEARING MEMORANDUM DATE: EMPLOYEE: COUNSEL FOR EMPLOYEE: ADDRESS: DATE OF INJURY: CLAIMS: 1. Section 34 from to 2. Section 35 from to 3. Section 36 in the amount of $ 4. Section 13 and 30 in the amount of $ 5. Section 31 from to or in the amount of $ 6. Section 28 from to or in the amount of $ 7. Other: Request Permission to Depose: Dr. TO BE COMPLETED BY COUNSEL FOR THE EMPLOYEE PRIOR TO HEARING Page 1 of 2 Form 161 - Revised 7/2019 - Reproduce as needed. The Commonwealth of Massachusetts Department of Industrial Accidents Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111 - 1750 Info. Line (800) 323 - 3249 Inside Mass. / (857) 321 - 7470 Outside Mass. www.mass.gov/dia (over) FORM 161 American LegalNet, Inc. www.FormsWorkFlow.com a. Stipulations of Fact: b. Witnesses at Hearing: 1. 2. 3. 4. 5. c. Exhibits to be Marked at Hearing: 1. 2. 3. 4. 5. d. Medical Reports [Under 452 CMR 1.11 (6)]: 1. 2. 3. 4. 5. qualifications. ISSUES TO BE ADDRESSED AT HEARING: Will an Interpreter be Needed?: YES NO Language to be Interpreted (if applicable): NOTE: The party offering testimony by a witness who requires an interpreter must provide a certified interpreter at the time of hearing. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com
