Form 108-A "Insurer's Request for Post-lump Sum Medical Mediation" - Massachusetts

What Is Form 108-A?

This is a legal form that was released by the Massachusetts Department of Industrial Accidents - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2019;
  • The latest edition provided by the Massachusetts Department of Industrial Accidents;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 108-A by clicking the link below or browse more documents and templates provided by the Massachusetts Department of Industrial Accidents.

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Download Form 108-A "Insurer's Request for Post-lump Sum Medical Mediation" - Massachusetts

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The Commonwealth of Massachusetts
FORM 108-A
DIA Board #
Department of Industrial Accidents – Department 108-A
(If Known):
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
INSURER’S REQUEST FOR
POST-LUMP SUM MEDICAL MEDIATION
INSURER MUST SEND A COPY OF THIS NOTICE TO THE EMPLOYEE AND THE EMPLOYEE’S REPRESENTATIVE
1. Insurance Carrier’s Name and Address:
2. Self-insured?:
Yes
No
If Yes, Please Give Self-insurer Number:
I
3. Name & Address of Insurer’s Attorney:
4. Telephone Number of Insurer’s Attorney:
N
S
U
5. Claim Representative’s Name:
6. Claim Representative’s Tel. Number & Ext.:
R
E
R
7. Insurer’s Case File Number:
8. Date of Lump Sum Approval (mm/dd/yyyy):
9. Employee’s Name (Last, First, Middle
10. Employee’s Social Security number*:
:
)
11. Employee’s Address (No., Street, City, State, Zip Code):
12. Date of Birth (mm/dd/yyyy):
E
M
P
14. First Day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy):
13. Date of Injury (mm/dd/yyyy):
L
O
Y
15. Name, Address & Telephone Number of Employee’s Attorney:
E
E
Tel. Number:
16. Employer’s Name & Address (No., Street, City, State, Zip Code):
17. REQUIRED:
Please provide the specific reasons for the request:
G
R
O
U
N
D
S
18. Insurer’s Signature:
19. Date Prepared (mm/dd/yyyy):
-
*Disclosure of Social Security number is voluntary. It will aid in the processing of documents.
Form 108-A
7/2019 - Reproduce as needed.
Please print clearly or type. Unreadable forms will be returned.
The Commonwealth of Massachusetts
FORM 108-A
DIA Board #
Department of Industrial Accidents – Department 108-A
(If Known):
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
INSURER’S REQUEST FOR
POST-LUMP SUM MEDICAL MEDIATION
INSURER MUST SEND A COPY OF THIS NOTICE TO THE EMPLOYEE AND THE EMPLOYEE’S REPRESENTATIVE
1. Insurance Carrier’s Name and Address:
2. Self-insured?:
Yes
No
If Yes, Please Give Self-insurer Number:
I
3. Name & Address of Insurer’s Attorney:
4. Telephone Number of Insurer’s Attorney:
N
S
U
5. Claim Representative’s Name:
6. Claim Representative’s Tel. Number & Ext.:
R
E
R
7. Insurer’s Case File Number:
8. Date of Lump Sum Approval (mm/dd/yyyy):
9. Employee’s Name (Last, First, Middle
10. Employee’s Social Security number*:
:
)
11. Employee’s Address (No., Street, City, State, Zip Code):
12. Date of Birth (mm/dd/yyyy):
E
M
P
14. First Day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy):
13. Date of Injury (mm/dd/yyyy):
L
O
Y
15. Name, Address & Telephone Number of Employee’s Attorney:
E
E
Tel. Number:
16. Employer’s Name & Address (No., Street, City, State, Zip Code):
17. REQUIRED:
Please provide the specific reasons for the request:
G
R
O
U
N
D
S
18. Insurer’s Signature:
19. Date Prepared (mm/dd/yyyy):
-
*Disclosure of Social Security number is voluntary. It will aid in the processing of documents.
Form 108-A
7/2019 - Reproduce as needed.
Please print clearly or type. Unreadable forms will be returned.