Request For Speedy Conference Because Of Hardship {131}

FORM 131 The Commonwealth of Massachusetts Department of Industrial Accidents Department 131 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 DIA Board # (If Known): REQUEST FOR SPEEDY CONFERENCE BECAUSE OF HARDSHIP Employer: Insurer: Date of Injury: DIA Region: Please indicate which of the following HARDSHIP CRITERIA applies and follow the instructions below: You are presently unemployed; You have exhausted other benefit sources (Public Assistance, Veterans Benefits, Private Insurance, Social Security, Unemployment Insurance), or do not qualify for same; You and your family have income and assets that are inadequate to provide basic necessities and comforts of life for you and your dependents; You have a foreclosure/eviction proceeding pending against you (attach copy); You received a notice of utility termination for non - payment (attach copy) and you have exhausted other sources of relief (explain briefly below). Multiple Insurers disputing coverage disability and causal relation are not in dispute. State briefly the specific facts that support your REQUEST FOR SPEEDY CONFERENCE BECAUSE OF HARDSHIP for reason(s) checked above or for other reasons stated below (use back of form or attach additional sheets if necessary). INSTRUCTIONS 1. Attach completed Affidavit Form (Form 132) and documentation supporting claim of hardship. 2. You may not file a Request for Speedy Conference Because of Hardship until your claim has been conciliated. 3. Mail to: Senior Judge, Division of Dispute Resolution Department of Industrial Accidents Lafayette City Center 2 Avenue de Lafayette Boston, MA 02111 - 1750 ----------------------------------------------------------------------------------------------------------------------------- --- -------- For Department Use Only REQUEST GRANTED REQUEST DENIED Signature of Senior Judge, Div. of Dispute Resolution: Date: Reproduce as Needed. Form 131 Revised 7/2019 American LegalNet, Inc. www.FormsWorkFlow.com ADDITIONAL SPACE American LegalNet, Inc. www.FormsWorkFlow.com