Notice Of Change Appearance Of Counsel Form. This is a Massachusetts form and can be use in Workers Comp.
Tags: Notice Of Change Appearance Of Counsel, 114, Massachusetts Workers Comp,
The Commonwealth of Massachusetts Department of Industrial Accidents – Department 114 FORM 114 600 Washington Street – 7th Floor, Boston, Massachusetts 02111 Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470 http://www.mass.gov/dia DIA Board # (If Known): NOTICE OF CHANGE / APPEARANCE OF COUNSEL THIS FORM MUST BE FILED WHEN AN ATTORNEY APPEARS AS LEGAL COUNSEL FOR THE FIRST TIME OR A CHANGE OF COUNSEL HAS OCCURRED. ALL PARTIES MUST BE NOTIFIED. PLEASE NOTE - WHEN AN ATTORNEY LEAVES A FIRM AND ANOTHER ATTORNEY IN THAT FIRM TAKES OVER ACTIVE CASES, AN APPEARANCE OF COUNSEL MUST BE FILED FOR EACH MATTER. Please Print or Type 1. Employee’s Name (Last, First, MI) : E M P 3. Employee’s Address (No. and Street, City, State, Zip Code): L O Check box if this is a new address Y 5. Employer’s Name & Address (No. and Street, City, State, Zip Code): E E 2. Employee’s Social Security Number*: 4. Date of Injury (mm/dd/yyyy): Check box if this is a new address Yes If Yes - Self Insurer #: & 6. Insurance Carrier’s Name: 7. Self-Insured?: No I 8. Insurance Carrier’s Address (No. and Street, City, State, Zip Code): N S. 9. PLEASE ENTER MY APPEARANCE FOR: Employee Insurer Third Party Other (Specify) ______________________________ 10. EMPLOYEE HAS DISCHARGED ME AS COUNSEL 11. COUNSEL HAS BEEN REPLACED BY SUCCESSOR COUNSEL AND IS WITHDRAWING FROM REPRESENTATION OF: Employee Insurer Third Party Other (Specify) ________________ Attach Appearance of Successor Counsel 12. COUNSEL FOR: Employee Insurer Third Party Other (Specify) ________________________ REQUESTS PERMISSION TO WITHDRAW PURSUANT TO 452 C.M.R. 1.18 (3) 13. APPROVED BY: ___________________________________ (Name) ________________________ (Title) __________________________________________________________________ (Signature) ON BEHALF OF THE DIVISION OF DISPUTE RESOLUTION _____________________________ (Date - mm/dd/yyyy) 14. Attorney’s Name & Address: Check box if this is a new address 15. Attorney’s Board of Bar Overseer’s Number: 16. Attorney’s Telephone Number: 17. Attorney’s Signature: 18. Date Prepared (mm/dd/yyyy): *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. Form 114 - Revised 8/2001 - Reproduce as needed. American LegalNet, Inc. www.USCourtForms.com