Third Party Claim Notice Of Lien Form. This is a Massachusetts form and can be use in Workers Comp.
Tags: Third Party Claim Notice Of Lien, 115, Massachusetts Workers Comp,
FORM 115 The Commonwealth of Massachusetts Department of Industrial Accidents – Department 115 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 THIRD PARTY CLAIM / NOTICE OF LIEN PLEASE CHECK ONE ONLY THIRD PARTY CLAIM NOTICE OF LIEN COPIES OF THIS FORM SHOULD BE PROVIDED TO THE INJURED EMPLOYEE AND THE INSURER IMPORTANT - SEE INSTRUCTIONS AND DEFINITIONS ON REVERSE SIDE Please Print or Type T H I R D P A R T Y 1. Name (Business or Individual): 2. Telephone Number: 3. Address (No. and Street, City, State, Zip Code): 5. Attorney’s Telephone Number: 6. Employee’s Name (Last, First, MI) : E M P L O Y E E 4. Attorney’s Name and Address (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): PLEASE NOTE - if this is a Notice of Lien fill out box 13 only. If this is a Third Party Claim fill out box 14 only. DO NOT FILL OUT BOTH BOXES. See reverse side of form for definitions and instructions. 13. If this is a lien, please state the nature of services rendered, the statutory basis therefore and the amount thereof: B E N E F I T O R S E R V I C E 14. If this is a claim for payment or reimbursement for services provided to the employee, please state the nature of services rendered, the statutory basis therefore and the amount thereof: 15. Preparer’s Signature: S I G N 16. Preparer’s Name (Please Print): 17. Date (mm/dd/yyyy): *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 115 - Revised 8/2001 - Reproduce as needed. American LegalNet, Inc. www.USCourtForms.com THIRD PARTY CLAIM / 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 (THIRD PARTY) - A Third Party Claim 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 third parties only when monies are owed under the definitions stated above. You must fill out the boxes in the “Third Party” and “Employee” sections to the best of your knowledge, but the employee name and address are required. If a lien is necessary, you should fill out box 13 only under the “Benefits or Services” section. If you are filing a third party claim, you should fill out box 14 only under the “Benefits or Services” section. DO NOT FILL OUT BOTH BOXES! Please note: A hearing pursuant to M.G.L. c 152 §46A must be scheduled, and approved, at the DIA for final lien discharge. American LegalNet, Inc. www.USCourtForms.com