The Commonwealth of Massachusetts Department of Industrial Accidents FORM 140 DIA Board # (If Known): 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 Page 1 of 2 TEMPORARY CONFERENCE MEMORANDUM COVER FORM Please Print or Type THIS CONFERENCE MEMORANDUM COVER SHEET , SIGNED BY COUNSEL SHALL BE FILED WITH THE ADMINISTRATIVE JUDGE AT THE START OF THE CONFERENCE. 1. Date (mm/dd/yyyy): C A S E 2. Conference Location: 3. DIA Board Number: 4. Claimant’s Name & Address (No., Street, City, State & Zip Code): 5. Claimant’s Tel. Number: 7. Claimant’s Attorney’s Tel. Number: I 6. Name and Address of Claimant’s Attorney: N F O R 8. Insurance Carrier’s Name & Address: M A T I 10. Employer’s Name & Address: O N E M P L O Y E E & I N J U R Y I S S U E S I N D I S P U T E 12. Date of Injury (mm/dd/yyyy): Tel. Number: 11. Name & Address of Employer’s Attorney: Tel. Number: 14. Average Weekly Wage: 15. No. of Dependents: 13. Nature & Cause of Injury: 16. Has Any Compensation Been Paid: Yes 9. Name & Address of Insurer’s Attorney: No 17. If Yes for #16 Please State Period and Type: From ____________ To _______________ and From _______________ to _______________ At a Rate of $____________________ per Week Under §34 Accepted Liability Pay Without Prejudice At a Rate of $____________________ per Week Under §35 - Plus Dependency at $__________ /week 18. Claims for Compensation: Temporary Total Incapacity - From _________________ To ______________ at $ _____________________ per week OR Partial Compensation - From _________________ To ______________ at $ _____________________ per week Section 36 Benefits ________________________ OTHER (specify) __________________________________________ 19. Issues in Dispute (Check all that apply): Liability - Average Weekly Wage - Disability - Extent - Causal Relationship to Work Fraud (explain ) _________________________________ §14 (1) OTHER (specify)________________________________________________________________ _______________________________________________________________________ §14 (2) Dispute of Entitlement Due to Insufficient Documentation Filed Other Attorney Fee Issues _____________________________________________________________ 20. Is Impartial Medical Examination Required?: Yes, Impartial Exam Will be needed - No Impartial Exam is needed (OVER) Form 140 - Revised 8/2001 Reproduce as needed. American LegalNet, Inc. www.USCourtForms.com Page 2 of 2 PURSUANT TO 452 C.M.R. 1.10 (2), AS AMENDED, CHECK OFF THE DOCUMENTATION INCLUDED IN ATTACHED CONFERENCE MEMORANDUM: DOCUMENTS TO BE SENT TO IMPARTIAL PHYSICIAN MUST BE SUBMITTED IN DUPLICATE AND ARRANGED IN CHRONOLOGICAL ORDER EMPLOYEE INSURER ATTACHMENTS: Stipulations of Fact. Exhibits to be marked for identification at hearing. Names of witnesses with summary of anticipated testimony. Medical records to be sent to impartial examiner, accompanied by an itemized list of those records. Hypotheticals to be sent to impartial. Disclosure questions for impartial physician (not to exceed 3 in number). Written objections to medical records submitted, starting with the reasons therefore. Name(s) of additional physician(s) for who(m), at the time of hearing, it is anticipated either party will request a deposition. PURSUANT TO 452 C.M.R. 1.10 (2), COMPLETE THE FOLLOWING: MEDICAL ISSUE(S) IN DISPUTE: MEDICAL SPECIALTY OF IMPARTIAL PHYSICIAN NAMES OF THREE IMPARTIAL PHYSICIANS THE PARTIES HAVE AGREED UPON IN ORDER OF PREFERENCE 1. CHECK THIS BOX IF NO AGREEMENT CAN BE REACHED - 2. 3. ESTIMATED LENGTH OF HEARING _________________________ SIGNATURES: EMPLOYEE’S COUNSEL _________________________ INSURER’S COUNSEL _________________________ EMPLOYER’S COUNSEL (if applicable) ______________________________ FOR DEPARTMENT USE ONLY DISPOSITION: ORD _____________________________ FROM ________________________ TO _____________________ ATTORNEY FEE: $__________________ ADDITIONAL TIME ALLOWED TO FILE DOCUMENTS: _______ DAYS American LegalNet, Inc. www.USCourtForms.com