Fillable Commonwealth of Massachusetts Department of Industrial Accidents Form-140 Conference Memorandum

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Commonwealth of Massachusetts Department of Industrial Accidents Form-140 Conference Memorandum

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The Commonwealth of Massachusetts Department of Industrial Accidents Form-140 Conference Memorandum form is 2 pages long and contains:

  • 2 signatures
  • 12 check-boxes
  • 47 other fields

Country of origin: US
File type: PDF

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The Commonwealth of Massachusetts
Department of Industrial Accidents
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
CONFERENCE MEMORANDUM
DIA Board #
(If Known):
FORM 140
Form 140 - Revised 7/2019
Reproduce as needed.
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1. Date (mm/dd/yyyy):
4. Name, Address & Email Address of Claimant’s Attorney:
5. Insurance Carrier’s Name & Address:
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2. List Multiple DIA Board Numbers If Necessary:
11. Average Weekly Wage:
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13. Has Any Compensation Been Paid:
Yes No Accepted Liability Pay Without Prejudice
3. Claimant’s Name & Address (No., Street, City, State & Zip Code):
15. Claims for Compensation:
Total Incapacity Under § _______From ____/____ /_____ To ______/______/______ at $ ___________ per week;
AND/OR
Partial Incapacity Under § _______From ____/____ /_____ To ______/______/______ at $ ___________ per week
§ 36 Benefits ________________________ OTHER (specify) __________________________________________
9. Date of Injury (mm/dd/yyyy):
14. If Yes for #13 Please State Period and Type:
From _____/_____ /_______ To ______/______/______ Under § __________ at $ _______________; and
From _____/_____/_______ To _____/______/______ Under § __________ at $ _______________
THIS CONFERENCE MEMORANDUM COVER SHEET , SIGNED BY COUNSEL SHALL
BE FILED WITH THE ADMINISTRATIVE JUDGE AT THE START OF THE CONFERENCE.
6. Name, Address & Email Address of Insurer’s Attorney:
7. Employer’s Name, Address & Email Address:
12. No. of Dependents:
16. Issues in Dispute (Check all that apply):
Liability Average Weekly Wage Disability Extent Causal Relationship to Work
Fraud (explain ) _________________________________ §14 (1) §14 (2)
OTHER (specify)________________________________________________________________
_______________________________________________________________________
Attorney Fee Issues _____________________________________________________________
Page 1 of 2
(OVER)
Please Print or Type
10. Nature & Cause of Injury:
8. Name, Address & Email Address of Employer’s Attorney:
Page 2 of 2
Medical documents for the Impartial Physician:
I certify that all medical documents (PDF, bookmarked, and text recognized) to be sent to the Impartial Physician have
been uploaded via CMS on or before the date of the scheduled Conference proceeding.
If hypothetical questions are submitted, they must be uploaded separately via CMS
Non-medical documents:
I certify that all non-medical documents (PDF, bookmarked and text recognized) have been uploaded via CMS
on or before the date of the scheduled Conference proceeding.
For Department Use Only
Disposition Order: ______________________________________________
From: _________________________________ To ________________________________
From: ________________________________ To ________________________________
Attorney’s Fee: _______________________________________________
Notes: _________________________________________________________________________________________
_________________________________________________________________________________________
PURSUANT TO 452 C.M.R. 1.10(2), COMPLETE THE FOLLOWING:
Medical Issue(s) in Dispute: ____________________________________________________________
Medical Specialty of the Impartial Physician: _________________________________________________
If there is agreement, name of the Impartial Physician: _______________________________________
Injured Body Part(s): __________________________________________________________________
If an Impartial is not needed, a separate Form 121A must be filed at Conference.
I certify the above to be complete and accurate:
Employee’s Attorney Signature: ____________________________________________________________
Print Name: ____________________________________________________________________________
Insurer’s Attorney Signature: ______________________________________________________________
Print Name: ____________________________________________________________________________
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Commonwealth of Massachusetts Department of Industrial Accidents Form-140 Conference Memorandum

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Completed 17 May 2020

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