AGREEMENT UNDER SECTION 37 or 37A
12. Total Amount to be reimbursed under Section 37 or 37A :
$___________________
14. Is employee still receiving weekly compensation benefits? Yes No If Yes, please fill out the following
TYPE OF WEEKLY COMPENSATION
COMPENSATION AMOUNT
I hereby certify that the information contained herein is a true accounting of all payments made to the above named employee.
________________________
________________________________________________________________
Signature of Insurer’s Authorized Representative
Prepared Date (mm/dd/yyyy)
_________________________________________________________________________________________
Name & title (Last, First, MI)
I hereby agree to and approve the following reimbursement to be made per the provisions of this agreement.
_______________________________________ __________________ _____________________________________________
Signature for the Office of Legal Counsel Date (mm/dd/yyyy) Name & title (Last, First, MI)
DIA BOARD NO.
§37 or §37A
Claim
a. Total Disability – Temporary (§34) $______________________________
b. Total Disability – Permanent (§34A) $______________________________
c. Partial Disability (§35) $______________________________
d. Dependent Coverage (§35A)
$______________________________
e. Surviving Dependents Coverage (§31) $______________________________
f. Other (Specify) ______________________ $______________________________
9. Paid Through (mm/dd/yyyy):
11. If Employee Died, Enter Date of Death:
Form 123 - Revised 7/2019
1. Employee’s Name (Last, First, MI):
2. Home Address (No. & Street, City, State, Zip Code):
3. Employer’s Name:
4. Employer’s Address (No. & Street, City, State, Zip Code):
5. Insurance Carrier’s Name: 6. Insurance Company Address:
7. Name & Address of Person Able to Verify Information:
8. Telephone Number:
E
M
P
L
O
Y
E
E
I hereby agree to and authorize the following reimbursement to be made per the provisions of this agreement.
Signature for the Office of the Commissioner
Date (mm/dd/yyyy) Name & title (Last, First, MI)
_______________________________________ __________________ _____________________________________________
FORM 123
The Commonwealth of Massachusetts
Department of Industrial Accidents – Department 123
Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111-1750
Info. Line (800) 323-3249 in Mass. / (857) 321-7470 Outside Mass.
www.mass.gov/dia
10. First Date of Disability (mm/dd/yyyy):
I
N
S
U
R
E
R
NEGOTIATED
FULL & FINAL
13. Amount of Quarterly Reimbursements (if any): $________________________
(Check all that apply
to this agreement)
Reproduce as needed.
Please print or type
Please Note – For Injuries on or after 12/23/1991, the insurer must file their quarterly request for reimbursement within
two (2) years from the date of the final approval of the Form 123. All subsequent quarterly request for reimbursements
must be received by the DIA within two (2) years from the date of payment by the insurer.
