E M P L O Y E E The Commonwealth of Massachusetts Department of Industrial Accidents Department 115 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 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 DIA Board # (If Known): FORM 115 Form 115 - Revised 7/2019 - Reproduce as needed. 1. Name (Business or Individual): 3. Address (No. and Street, City, State, Zip Code): ) : 11. Date of Injury (mm/dd/yyyy): T H I R D P A R T Y 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. 9. Date of Birth (mm/dd/yyyy): 17. Date (mm/dd/yyyy): 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 service s r endered, the statutory basis therefore and the amount thereof: S I G N Please Print or Type 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. American LegalNet, Inc. www.FormsWorkFlow.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 and 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 or section . If you are filing a third party claim, you should fill out box 14 only under the or section . DO NOT FILL OUT BOTH BOXES! Please note : A hearing pursuant to M . G . L . c 152 247 46 A must be scheduled, and approved, at the DIA for final lien discharge . 10 ( 1 ) states for an attorney fee to be due under 247 13 A "such claim shall have been sent to the insurer by certified mail" . Also in order for any attorney's fee to be due for services involving a claim for health care services, such claim shall include a copy of any relevant bill and a description from the health care provider of the services rendered . American LegalNet, Inc. www.FormsWorkFlow.com