Agreement That No Impartial Physician Report Is Required {121A}

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 THAT NO IMPARTIAL PHYSICIAN REPORT IS REQUIRED FORM 121A THIS FORM MUST BE SUBMITTED TO THE ADMINISTRATIVE JUDGE IN A TIMELY FASHION. Please Print or Type EMPLOYEE BOARD NUMBER Pursuant to 452 C.M.R. 1.10 the parties make the following agreement under the subsection identified below: (5) The disputed matter concerns a 247 7A and/or death case. (5) Dispute over entitlements of prior disability benefits. (6) Agreement upon partial disability and causal relationship. (7) Agreement that initial liability has not been established. PARTIES: Pursuant to 452 C.M.R. 1.11(1)(d) at the discretion of the administrative judge at the hearing, the parties have been allowed to make the agreements indicated above. ADMINISTRATIVE JUDGE ----------------------------------------------- FOR INTERNAL USE ONLY ------------------------------------------- Impartial Exam Date Fee Date Docketing Unit Processed By Date Impartial Unit Processed By Date Form 121A - Revised 7/2019 Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com