COMPENSATION: $ ADMINISTRATIVE JUDGE DATE 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 LAST BEST OFFER AT CONFERENCE DIA Board # (If Known): FORM 141 Please Print or Type This form is for use at conference pursuant to M.G.L. Chapter 152, sec. 10A(2) in cases involving claims for further EMPLOYEE: EMPLOYER: INSURER: DIA BOARD #: - $ Brief Description of basis for offer: Submitted by: Date (mm/dd/yyyy): - $ Brief Description of basis for offer: Submitted by: Date (mm/dd/yyyy): Form 141 - Revised 7/2019 - Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com