JUDGE’S FINDING IF DIFFERENT FROM ABOVE:
COMPENSATION: $
BASIS FOR JUDGE’S FINDING:
___________________________________
ADMINISTRATIVE JUDGE DATE
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
LAST BEST OFFER AT CONFERENCE
DIA Board #
(If Known):
FORM 141
Please Print or Type
This form is for use at conference pursuant to M.G.L. Chapter 152, sec. 10A(2) in cases involving claims for further
weekly compensation or complaints for discontinuance or modification of such compensation when the insurer’s
liability for the employee’s industrial injury has already been established.
EMPLOYEE: ___________________________________________________________
EMPLOYER: ___________________________________________________________
INSURER: ___________________________________________________________
DIA BOARD #: ___________________________________________________________
Employee’s offer for weekly compensation - $________________________________
Brief Description of basis for offer:
Submitted by: ______________________________ Date (mm/dd/yyyy):
Insurer’s offer for weekly compensation - $________________________________
Brief Description of basis for offer:
Submitted by: ______________________________ Date (mm/dd/yyyy):
Form 141 - Revised 7/2019 - Reproduce as needed.
