Consent Of Employer To Lump Sum Settlement {116A}

FORM 116A The Commonwealth of Massachusetts Department of Industrial Accidents Department 116A 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): I,, sole proprietor/partner/corporate officer of (business name) located at (address) , (city) (state) and experience - modified insured of hereby consent to payment of a lump sum settlement in the gross amount of case of . The terms of such settlement are more fully set forth in the attached lump sum agreement. Signed this day of , 20 , pursuant to the provisions of Section 48 of Chapter 152 of the General Laws of Massachusetts as most recently amended by Section 74 of Chapter 398 of the Acts of 1991. (signature) Reproduce as needed. Form 116A Revised 7/2019 CONSENT OF EMPLOYER TO LUMP SUM SETTLEMENT American LegalNet, Inc. www.FormsWorkFlow.com