O T H E R P A R T I E S The Commonwealth of Massachusetts Department of Industrial Accidents - Central Scheduling Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111 - 1750 Info. Line (800) 323 - 3249 (in Mass.) / (857) 321 - 7470 (Out of Mass) www.mass.gov/dia DIA Board # (If Known): FORM 46A Form 46A - Reproduce as needed Revised 7/2019 1. Name (Business or Individual): 3. Address (No. and Street, City, State, Zip Code): 5. Telephone Number: ) : 11. Date of Injury (mm/dd/yyyy): L I E N H O L D E R 2. Telephone Number: *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. 4. Name and Address of Attorney or representative (No. and Street, City, State, Zip Code): 9. Date of Birth (mm/dd/yyyy):20. Date (mm/dd/yyyy): 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 Please Print or Type 13. Self - Insured Yes No If Yes, Self - Insurer number REQUEST FOR 247 46A CONFERENCE INCONJUNCTION WITH LUMP SUM UNDER 247 48 BOSTON FALL RIVER LAWRENCE SPRINGFIELD WORCESTER *A l ien for legal services is not amenable to discharge or compromise under the provisions of 247 46A . Please state the total amount of the lien: $ 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 ( 247 46 A ) - A 247 46 A 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 152 247 46 A must be scheduled, and approved, at the DIA for final lien discharge . American LegalNet, Inc. www.FormsWorkFlow.com