FORM 114 The Commonwealth of Massachusetts Department of Industrial Accidents Department 114 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 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. DIA Board # (If Known): Form 114 - Revised 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. 18. Date Prepared (mm/dd/yyyy): E M P L O Y E E & I N S. 9. PLEASE ENTER MY APPEARANCE FOR: Employee Insurer Third Party Other (Specify) Please Print or Type ) : 4. Date of Injury (mm/dd/yyyy): 7. Self - Insured?: Yes No If Yes - Self Insurer #: 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 COUNSEL HAS BEEN REPLACED BY SUCCESSOR COUNSEL AND IS WITHDRAWING FROM REPRESENTATION OF: Employee Insurer Third Party Other (Specify) Attach Appearance of Successor Counsel 12.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) Check box if this is a new address Check box if this is a new address Check box if this is a new address American LegalNet, Inc. www.FormsWorkFlow.com