The Commonwealth of Massachusetts Department of Industrial Accidents Department 108 - A 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 POST - LUMP SUM MEDICAL MEDIATION DIA Board # (If Known): FORM 108 - A Form 108 - A - 7/2019 - Reproduce as needed. *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. E M P L O Y E E ) : I N S U R E R 2. Self - insured?: Yes No If Yes, Please Give Self - insurer Number: 8. Date of Lump Sum Approval (mm/dd/yyyy): G R O U N D S 12. Date of Birth (mm/dd/yyyy): 19. Date Prepared (mm/dd/yyyy): 14. First Day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy): 13. Date of Injury (mm/dd/yyyy): INSURER MUST Tel. Number: 17. REQUIRED: Please provide the specific reasons for the request: American LegalNet, Inc. www.FormsWorkFlow.com