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Insurers Complaint For Modification Discontinuance Or Recoupment Of Compensation Form. This is a Massachusetts form and can be use in Workers Comp.
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Tags: Insurers Complaint For Modification Discontinuance Or Recoupment Of Compensation, 108, Massachusetts Workers Comp,
FORM 108 The Commonwealth of Massachusetts Department of Industrial Accidents Department 108 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 DIA Board # (If Known): INSURER'S COMPLAINT FOR MODIFICATION, DISCONTINUANCE OR RECOUPMENT OF COMPENSATION CHECK ONE BOX: MODIFICATION DISCONTINUANCE RECOUPMENT INSURER MUST SEND A COPY OF THIS NOTICE TO THE EMPLOYEE AND THE EMPLOYEE'S REPRESENTATIVE 1. Insurance Carrier's Name and Address: 2. Self-insured?: Yes No If Yes Please Give Self-insurer Number: 4. Telephone Number of Insurer's Attorney: I N S U R E R 3. Name & Address of Insurer's Attorney: 5. Claim Representative's Name: 7. Insurer's Case File Number: 6. Claim Representative's Tel. Number & Ext.: 8. Did Insurer Receive First Report of Injury (Form 101); Yes No - If Yes - Date Received (mm/dd/yyyy): 10. Employee's Social Security Number*: 9. Employee's Name (Last, First, MI): 11. Employee's Address (No. and Street, City, State, Zip Code): E M P L O Y E E 12. Date of Birth (mm/dd/yyyy): 13. Date of Injury (mm/dd/yyyy): 14. First Day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy): 15. Name, Address & Telephone Number of Employee's Attorney: Tel. Number 16. Employer's Name & Address (No. and Street, City, State, Zip Code): 17. This is the Insurer's Request to MODIFY Weekly Compensation Attach Proper Documents Under 452 CMR 1.07(I) Attach Proper Documents Under 452 CMR 1.07(J) Attach Proper Documents Under 452 CMR 1.07(K) This is the Insurer's Request to DISCONTINUE Weekly Compensation This is the Insurer's Request to RECOUP Weekly Compensation 18. Give Specific Basis for Complaint (continue on reverse side if necessary): G R O U N D S 19. Insurer's Signature : 20. Date Prepared (mm/dd/yyyy): Form 108 - Revised 7/2013- Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com *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. Explanation of Box 18 continued: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com
