Agreement For Redeeming Liability By Lump Sum - For Injuries Before 11-1-86 {117A}

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 AGREEMENT FOR REDEEMING LIABILITY BY LUMP SUM UNDER G.L. CH. 152, 247 48 FOR INJURIES OCCURRING BEFORE NOV. 1, 1986 DIA Board # (If Known): FORM 117A Board Number Employee Insurer Or Self - insurer Employer LUMP SUM AMOUNT $ Total Deductions $ Net to Claimant $ Received of the Lump Sum of dollars and cents ($) making with weekly pay ments already received by me , the total sum of dollars and cents ($). Said payments are received in redemption of the liability for all weekly payments now or in the future due Compensation Act, for all injuries received by on or about while in the employ of subject to the approval of the Department of Industrial Accidents . Date of Agreem ent STRIKE OUT IF NOT APPLICABLE I understand that from the LUMP SUM amount stated above, the amounts listed below will be deducted and paid to the following par ties: 1. $ Address Address 2. $ Liens 3. $ 4. $ 5. $ 6. $ 7. $ STRIKE OUT IF NOT APPLICABLE I understand that, in addition to the LUMP SUM amount stated above, the insurer or self - insurer will pay all outstanding reasona ble medical bills incurred as of this date: I understand that after all of the above deductions, including attorneys fees and other liens, I will receive the net amount of $. I further understand that this is a complete and final settlement of my claim and that I will not be able to reopen my claim or seek further benefits because of this injury. I am fully satisfied with this settlement . (over) Page 1 of 2 Please Print or Type American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Employee: Age: Average Weekly Wage: Dependents: Comp. Rate: Social Security No.*: On Social Security Disability: Yes No Occupation: If yes, from what date?: Injury: Nature: Place and Date of all injuries included Cause: Liability: Accepted: Yes No If No, state reason If accepted, what is pending issue: Medical: Original Diagnosis: Present Medical Condition: Present Work Capacity: PERTINENT MEDICAL REPORTS AND BILLS SHOULD BE ATTACHED HERETO COMPENSATION PAID: 247 34 $ 247 35A $ 247 34A $ 247 35 $ 247 36 $ 247 31 $ PLEASE GIVE A BRIEF HISTORY OF THE CASE AND INDICATE WHY THE SETTLEMENT IS Signatures: Counsel for Insurer Counsel for Employee *Disclosure of Social Security Number is Voluntary. It will aid in the processing of this document. Form 117A - Revised 7/2019 - Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com