The Commonwealth of Massachusetts Department of Industrial Accidents Department 19 - A Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111 - 1750 Info. Line: (800) 323 - 2149 (Inside Mass.) \ (857) 321 - 7470 (Outside Mass.) www.mass.gov/dia FORM 19 - A Form 19 - A - 7/2019 - Reproduce as needed. 3 Employer Name and Address (No., Street, City, State, Zip): 4. Insurer/Address (No., Street, City, State, Zip): 7. Date (mm/dd/yyyy): 8. Employee Counsel Signature : 9. Date (mm/dd/yyyy): *Disclosure of Social Security Number is Voluntary. It will aid in the processing of your claim. 6. Employee/Claimant Signature: ( REQUIRED) SECTION 19 - A MEDICAL MEDIATION AGREEMENT 11. Date (mm/dd/yyyy): 10. Insurer Counsel/Claims Rep. Signature: APPROVAL FOR THE DEPARTMENT BY: NAME: TITLE: DATE: DIA Board # (if known) 5. Date of Injury (mm/dd/yyyy): THE PARTIES AGREE AS FOLLOWS: 2. Social Security Number * : ATTORNEY FEE : $ American LegalNet, Inc. www.FormsWorkFlow.com