Request For Section 46a Conference With Lump Sum Under Section 48
Request For Section 46a Conference With Lump Sum Under Section 48 Form. This is a Massachusetts form and can be use in Workers Comp.
Tags: Request For Section 46a Conference With Lump Sum Under Section 48, 46A, Massachusetts Workers Comp,
FORM 46A The Commonwealth of Massachusetts Department of Industrial Accidents - Central Scheduling 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 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): REQUEST FOR §46A CONFERENCE IN CONJUNCTION WITH LUMP SUM UNDER §48 Please Print or Type L I E N H O L D E R BOSTON FALL RIVER LAWRENCE SPRINGFIELD WORCESTER 1. Name (Business or Individual): 2. Telephone Number: 3. Address (No. and Street, City, State, Zip Code): P A R T I E S 5. Telephone Number: 6. Employee’s Name (Last, First, MI): O T H E R 4. Name and Address of Attorney or representative (No. and Street, City, State, Zip Code): 7. Employee’s Social Security Number*: 8. Employee’s Address (No. and Street, City, State, Zip Code): 9. Date of Birth (mm/dd/yyyy): 10. Employer’s Name & Address (No. and Street, City, State, Zip Code): 11. Date of Injury (mm/dd/yyyy): 12. Insurance Carrier’s Name and Address (No. and Street, City, State, Zip Code): 13. Self-Insured Yes If Yes, Self-Insurer number 14. Name & Address of Insurer Carrier’s Attorney (No. & Street, City, State, Zip Code): 15. Attorney’s Telephone Number: No 16. Please state in detail the nature of the services which form the basis for the lien: B E N E F I T P R O V I D E D S I G N 17. P lease state the total amount of the lien: $________________________________ 18. Preparer’s Signature: 19. Preparer’s Name (Please Print): 20. Date (mm/dd/yyyy): *A lien for legal services is not amenable to discharge or compromise under the provisions of §46A *Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents. Please Print Legibly or Type - Unreadable forms will be returned. Form 46A - Reproduce as needed Revised 3/2011. American LegalNet, Inc. www.FormsWorkFlow.com NOTICE OF LIEN INSTRUCTIONS AND DEFINITIONS Pursuant to M.G.L. c. 152: LIEN - a lien may be filed by any party, business, organization or governmental agency that is owed monies for the following reasons including, but not limited to, unpaid legal bills, non-payment for services rendered, unpaid taxes, cash assistance for medical payments related to a compensable injury by the Division of Medical Assistance, and back child support. CLAIM (§46A ) - A §46A Claim for Reimbursement for accident and health insurance benefits paid on compensable injuries; lien of insurers, et al, against award; child support claims may be filed by a medical professional or other service provider when payment for services directly related to a compensable injury has been denied by an insurer. INSTRUCTIONS - This form should be filled out by parties only when monies are owed under the definitions stated above. To facilitate the processing of the form all sections must be completed. Please note: A conference pursuant to M.G.L. c 152 §46A must be scheduled, and approved, at the DIA for final lien discharge. American LegalNet, Inc. www.FormsWorkFlow.com