FORM 117 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 DIA Board # (If Known): AGREEMENT FOR REDEEMING LIABILITY BY LUMP SUM UNDER G.L. CH. 152 FOR INJURIES OCCURRING ON OR AFTER NOV. 1, 1986 Page 1 of 2 Please Print or Type EMPLOYEE LUMP SUM AMOUNT $ EMPLOYER TOTAL DEDUCTIONS $ INSURER NET TO CLAIMANT $ BOARD NUMBER TOTAL PAYMENTS $ (Weekly benefits plus lump sum) DATE OF INJURY CHECK WHERE APPLICABLE: ( ) Liability has been established by acceptance or by standing decision of the Board, the Reviewing Board, or a court of the Commonwealth and this settlement shall not redeem liability for the payment of medical benefits and vocational rehabilitation benefits with respect to such injury. ( ) Liability has NOT been established by standing decision of the Board, the Reviewing Board, or a court of the Commonwealth and this settlement shall redeem liability for the payment of medical benefits and vocational rehabilitation benefits with respect to such injury. ( ) In addition to the lump - sum, the insurer agrees to pay all outstanding reasonable and related medical bills incurred as of this date. ( ) The employee is currently receiving a cost - of - living adjustment. ( ) represents payment to the employee of $ per month for life pursuant to Sciarotta v. Bowen , 837 F.2d. 135 (3d Cir., 1988). DEDUCTIONS: From the lump - sum amount as stated above, the amount(s) listed below will be deducted and paid directly to the follo wing parties: NAME ADDRESS 1. $ 2. $ (Please attach documentation) 3. $ Liens (Please attach discharges) 4. $ Inchoate Rights (Please specify release) 5. $ 6. $ 7. $ (OVER) Form 117 Revised 7/2019 - Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com PLEASE GIVE A BRIEF HISTORY OF THE CASE AND INDICATE WHY THE SETTLEMENT IS SIGNATURE ADDRESS ZIP CODE CLAIMANT: COUNSEL: COUNSEL: Signed this day of 20 Received of the Lump Sum of dollars and cents ($) This payment is received in redemption of the liability of all weekly payments now or in the future due Compensation Act, for all injuries received by on or about while in the employ of . I fully understand that after all of the deductions herein I will receive $. I am fully satisfied with and request approval of this settlement. This agreement has been translated for me into my native language of . (Please attach a separate sheet if necessary.) AGREEMENT FOR REDEEMING LIABILITY BY LUMP SUM SETTLEMENT EMPLOYEE MEDICAL INFORMATION: Age No. of Dependents Average Weekly Wage $ Compensation Rate $ Social Security No.*: - - Occupation Educational Background On Social Security: YES ( ) NO ( ) On Public Employee Disability Retirement: YES ( ) NO ( ) DIAGNOSIS PRESENT MEDICAL CONDITION Present Work Capacity: Third Party Action (Page 2 of 2) *Disclosure of Social Security Number is Voluntary. It will aid in the processing of this document. American LegalNet, Inc. www.FormsWorkFlow.com