Section 19 Agreement {19}

FORM 19 The Commonwealth of Massachusetts Department of Industrial Accidents ­ Department 19 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 Info. Line 800-323-3249 ext. 7470 in Mass. Outside Mass. 617-727-4900 ext. 7470 http://www.mass.gov/dia DIA Board # (if known) SECTION 19 AGREEMENT 1. Employee's Name (Last, First, MI) and Address (No., Street, City, State, Zip): 3 Employer/Address (No., Street, City, State, Zip): 4. Insurer/Address (No., Street, City, State, Zip): 5. Date of Injury (mm/dd/yyyy): 2. Social Security Number*: Now come the parties in the above-referenced action and agree to the following on a: Without Prejudice Without Liability With Prejudice With Liability Does this agreement close out the current litigation? Yes No Not Applicable If the answer is no, what issues remain in dispute? _________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ This agreement does not forfeit the parties' rights to raise any other claims or defenses. 6. Employee/Claimant Signature: 8. Employee Counsel Signature: 10. Insurer Counsel/Claims Rep. Signature: 7. Date (mm/dd/yyyy): 9. Date (mm/dd/yyyy): 11. Date (mm/dd/yyyy): APPROVAL FOR THE DEPARTMENT BY: NAME: __________________________________ TITLE: _____________________________ DATE:______________ *Disclosure of Social Security Number is Voluntary. It will aid in the processing of your claim. Form 19 - 8/2014 - Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com SECTION 19 AGREEMENT FILING INSTRUCTIONS PENALTIES UNDER M.G.L.c. 152 § 8(1) SHALL RESULT IF PAYMENT, PURSUANT TO THIS AGREEMENT, IS NOT MADE WITHIN 14 DAYS OF THE INSURER'S RECEIPT OF THE APPROVED DOCUMENT. THE ORIGINAL FORM MUST BE FILED WITH THE DEPARTMENT AND WILL NOT BE RETURNED TO THE PARTIES. 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