The Commonwealth of Massachusetts
Department of Industrial Accidents – Department 121
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
APPEAL OF CONFERENCE PROCEEDING
DIA Board #
(If Known):
FORM 121
Form 121 - Revised 7/2019 - Reproduce as needed.
*Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents.
Please Print Clearly or Type. Unreadable forms will be returned.
1. Case Appealed By:
Employee Insurer Other(Specify)
2. Medical Issue (Check one only):
Appeal fee attached
Appeal fee to be submitted to Department 121
Form 136, Waiver Request due to Indigence filed with Commissioner
Enlarge time frame to submit fee filed with Director
8. Employer’s Name & Address (No. and Street, City, State, Zip Code):
13. Preparer’s Signature (“On-File” is NOT acceptable. Must have signature.):
3. Non-Medical Issue:
4. Date of Order (mm/dd/yyyy):
7. Employee’s Name & Address (No. and Street, City, State, Zip Code):
14. Date Prepared (mm/dd/yyyy):
6. Date of Injury (mm/dd/yyyy):
A COPY OF THE ADMINISTRATIVE JUDGE’S ORDER SHOULD BE ATTACHED TO THIS APPEAL.
5. Name of Judge Who Issued Order:
9. Insurance Carrier’s Name & Address (No. and Street, City, State, Zip Code):
12. Preparer’s Name, Address (No. and Street, City, State, Zip Code) and Telephone #:
10. Name, Address & Telephone # of Insurer’s Attorney:
11. Name, Address & Telephone # of Employee’s Attorney:
Please Print or Type
INSTRUCTIONS ON THE REVERSE SIDE
7A. Social Security Number*:
