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 MOTION FOR EXPEDITED CONFERENCE DIA Board # (If Known): FORM 125 Please Print or Type This form is used to request an expedited conference relating to: Fraudulent Behavior, Illegal Discontinuance of Compensation ; Catastrophic Injuries and Denial Pursuant to 15A. Instructions are on the reverse side. Please type or print. EMPLOYEE: EMPLOYER: INSURER/SELF INSURER: Now comes the employee/claimant insurer/self - insurer and requests an expedited conference relating to (check one): Fraudulent Behavior Medical Emergencies Illegal Discontinuance of Compensation Controversy under 247 15A as to which Catastrophic Injuries of two or more insurers is liable State briefly the specific facts and legal grounds asserted in support of motion. Affidavits in support of Motion may be attached to this form. (If necessary use additional space on reverse side or attach second sheet.) CERTIFICATE OF SERVICE I, , attorney for , hereby certify that I have this date served on the this motion, together with any documents in support thereof, by mailing copies of same, via first class mail, postage prepaid, to: Date: **FOR DEPARTMENT USE ONLY** Motion Allowed Administrative Law Judge Motion Denied Date Form 125 Reproduce as Needed Revised 7/2019 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR PREPARATION AND FILING OF MOTION 1. No motion for expedited conference may be filed unless and until the underlying claim is first conciliated. 2. The reverse side of this form must be completed and signed by the legal representative of the moving party. Missing information may result in delay of assignment to a motion session. 3. The original and three (3) copies of the motion and any documents in support thereof must be mailed to: Central Scheduling Unit Department of Industrial Accidents The Lafayette City Center 2 Avenue de Lafayette Boston, MA 02111 - 1750 4. A copy of the motion and supporting documents must be mailed to the legal representative of the other party. (See Certificate of Service on reverse side of the form). 5. Return envelopes with sufficient postage pre - paid, pre - addressed to each interested party, must be submitted with the motion . If the Board elects to hear oral arguments on the motion, it will notify the parties of the date, time and place for hearing the motion. The signature of an attorney to a motion constitutes a certificate by him/her that he/she has read the motion and accompanying documents; that to the best of his/her knowledge, the information and belief there is a reasonable ground to support it; and that it is not interposed for delay. If it is determined that any party has filed or defended a motion for expedited conference without reasonable ground, the whole cost of the proceedings shall be assessed upon that party pursuant to MGL c. 152, 14(1). Additional Space: American LegalNet, Inc. www.FormsWorkFlow.com