2. DIA Board No. for Subsequent Injury: 4. Home Address (No. & Street, City, State, Zip Code): 6. Name of Insurer: 8. Address of Branch Responsible for Case: 9. Attorney for Insurer (Name & Address): E M P L O Y E E I N S U R E R 3. Date of Subsequent Injury: DIA USE ONLY REQUEST FOR SECTION 37 OR 37A PROCEEDING Check Box: 247 37 Claim 247 37A Claim FORM 122 The Commonwealth of Massachusetts Department of Industrial Accidents Department 122 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 Check boxes below to identify all sections of M.G.L. c. 152 relevant to the reimbursement you seek. Reimbursement for Payments for Subsequent Injury occurring before December 23, 1991: 247 30 and 247 30A Medical Services and Reports; 247 31 and 247 32 Surviving Dependents Coverage; 247 33 Burial Expenses; 247 34 Total Incapacity and 247 34A Permanent and Total Incapacity; 247 35 Partial Incapacity and 247 35A Dependent Compensation 247 36 Specific Permanent Injuries and 247 36A Death. Reimbursement for Payments for Subsequent Injury occurring on or after December 23, 1991: 247 31 and 247 32 Surviving Dependents Coverage; 247 33 Burial Expenses; 247 34A Permanent and Total Disability; 247 36A Death; 247 30 Medical: only for benefits due under above sections. Reimbursable Payments made after 104th Week from the date of onset of Disability or Death. (Please indicate Section, Dates, Weeks, Amounts and Total Payments): 1. 247 to = weeks $ 4. 247 to = weeks $ 2. 247 to = weeks $ 5. 247 to = weeks $ 3. 247 to = weeks $ 6. 247 to = weeks $ Total Payments: $ Reproduce as needed. See Reverse for Filing Requirements. Form 122 - Revised 7/2019 Lump Sum (with attorney fees + expenses deducted) Date: Amount: $ Medical Bills for Reimbursable Services after 104 th Week Amount: $ 17. Date Prepared (mm/dd/yyyy): 15. Certificate of Service Attached: Yes No Benefit Status 11. 104th Week From Disability (mm/dd/yyyy): 12. Is Employee still receiving compensation ?: 13. Is pre - existing physical impairment due to: Previous Accident Previous Disease Congenital Condition Petition Yes No Please Print or Type American LegalNet, Inc. www.FormsWorkFlow.com REQUIREMENTS TO FILE CLAIMS UNDER 247247 37/37A 1. After you file this claim it will be scheduled for conciliation in the Boston Office unless the parties agree in writing, at the time of the filing, that it is to be adjudicated at a specified regional office. 2. A claim requesting reimbursement under M.G.L. c. 152, 247247 37 and 37A shall be made on Form 122 and it shall be accompanied by both a certificate stating that it was served on the Office of Legal Counsel, and by a petition which sets forth and documents items which include, but are not limited to, the following: M.G.L. c. 152, 247247 - existing physical impairment due to a previous accident, disease or congenital condition as evidenced by such documents as a job application, a pre - not later than 30 days after the date of employment, or (for injuries occurring prior to12/23/91) by medical records which existed prior to the date of the subsequent impairment. c) Evidence that a known pre - existing physical impairment was, or was likely to be, a hindrance or obstacle to employment (i.e. medical records evidencing permanent physical restrictions, documented job modifications or accommodations which employer made on behalf of employee). d) All medical records pertaining to the subsequent impairment including attending physician reports, insurance medical examinations, and DIA impartial physician report. e) From the compensation claim involving the second injury, copies of all DIA documents which substantiate the reimbursement which the petitioner seeks, such as: (1) Employee Claim Form (110) (2) First Report of Injury (3) Agreement(s) to Compensation (4) Conference Orders, Hearing Decisions and Lump Sum Agreement f) Indemnity record for all reimbursable compensation paid after the 104 th week from the date of the onset of disability or death that clearly identify the claimant, the section under which compensation was paid, the dates for which payment was made, and the amount of weekly compensation. g) Medical bills paid for all related reimbursable medical treatment received by employee after the 104 th week from the date of the onset of disability. (Computer printouts which clearly identify the claimant, the service providers, and the dates of service constitute satisfactory documentation). h) A description of the subsequent impairment which includes an authoritative medical statement as to how the subsequent impairment is substantially greater (by the combined effects of such impairment and subsequent personal injury) than the disability that would have resulted from the subsequent personal injury alone, or that the subsequent injury was caused by the pre - existing impairment, and, if death results from the subsequent injury, that the death would not have occurred except for such pre - existing physical impairment. 3. Any matter not resolved at conciliation shall be scheduled for conference before an administrative judge unless parties agree to an alternative method of resolution as provided in M.G.L. c. 152, 247 10 B. American LegalNet, Inc. www.FormsWorkFlow.com