Form 123 "Agreement Under Section 37 or 37a" - Massachusetts

What Is Form 123?

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 123 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 123 "Agreement Under Section 37 or 37a" - Massachusetts

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The Commonwealth of Massachusetts
DIA BOARD NO.
FORM 123
Department of Industrial Accidents – Department 123
§37 or §37A
Claim
Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111-1750
Info. Line (800) 323-3249 in Mass. / (857) 321-7470 Outside Mass.
www.mass.gov/dia
Please print or type
AGREEMENT UNDER SECTION 37 or 37A
Please Note – For Injuries on or after 12/23/1991, the insurer must file their quarterly request for reimbursement within
two (2) years from the date of the final approval of the Form 123. All subsequent quarterly request for reimbursements
must be received by the DIA within two (2) years from the date of payment by the insurer.
1. Employee’s Name (Last, First, MI):
E
M
2. Home Address (No. & Street, City, State, Zip Code):
P
L
O
3. Employer’s Name:
Y
E
4. Employer’s Address (No. & Street, City, State, Zip Code):
E
5. Insurance Carrier’s Name:
6. Insurance Company Address:
I
N
S
7. Name & Address of Person Able to Verify Information:
U
R
E
8. Telephone Number:
R
10. First Date of Disability (mm/dd/yyyy):
11. If Employee Died, Enter Date of Death:
9. Paid Through (mm/dd/yyyy):
(Check all that apply
NEGOTIATED
: $___________________
12. Total Amount to be reimbursed under Section 37
or 37A
to this agreement)
FULL & FINAL
13. Amount of Quarterly Reimbursements (if any): $________________________
14. Is employee still receiving weekly compensation benefits?
Yes
No
If Yes, please fill out the following
TYPE OF WEEKLY COMPENSATION
COMPENSATION AMOUNT
Total Disability – Temporary (§34)
a.
$______________________________
Total Disability – Permanent (§34A)
b.
$____________ _ _________________
c.
Partial Disability (§35)
$______________________________
$______________________________
d.
Dependent Coverage (§35A)
e.
Surviving Dependents Coverage (§31)
$______________________________
f.
Other (Specify) ______________________
$______________________________
I hereby certify that the information contained herein is a true accounting of all payments made to the above named employee.
________________________________________________________________
________________________
Signature of Insurer’s Authorized Representative
Prepared Date (mm/dd/yyyy)
_________________________________________________________________________________________
Name & title (Last, First, MI)
I hereby agree to and approve the following reimbursement to be made per the provisions of this agreement.
_______________________________________ __________________
_____________________________________________
Signature for the Office of Legal Counsel
Date (mm/dd/yyyy)
Name & title (Last, First, MI)
I hereby agree to and authorize the following reimbursement to be made per the provisions of this agreement.
_______________________________________ __________________
_____________________________________________
Date (mm/dd/yyyy)
Name & title (Last, First, MI)
Signature for the Office of the Commissioner
Reproduce as needed.
Form 123 - Revised 7/2019
The Commonwealth of Massachusetts
DIA BOARD NO.
FORM 123
Department of Industrial Accidents – Department 123
§37 or §37A
Claim
Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111-1750
Info. Line (800) 323-3249 in Mass. / (857) 321-7470 Outside Mass.
www.mass.gov/dia
Please print or type
AGREEMENT UNDER SECTION 37 or 37A
Please Note – For Injuries on or after 12/23/1991, the insurer must file their quarterly request for reimbursement within
two (2) years from the date of the final approval of the Form 123. All subsequent quarterly request for reimbursements
must be received by the DIA within two (2) years from the date of payment by the insurer.
1. Employee’s Name (Last, First, MI):
E
M
2. Home Address (No. & Street, City, State, Zip Code):
P
L
O
3. Employer’s Name:
Y
E
4. Employer’s Address (No. & Street, City, State, Zip Code):
E
5. Insurance Carrier’s Name:
6. Insurance Company Address:
I
N
S
7. Name & Address of Person Able to Verify Information:
U
R
E
8. Telephone Number:
R
10. First Date of Disability (mm/dd/yyyy):
11. If Employee Died, Enter Date of Death:
9. Paid Through (mm/dd/yyyy):
(Check all that apply
NEGOTIATED
: $___________________
12. Total Amount to be reimbursed under Section 37
or 37A
to this agreement)
FULL & FINAL
13. Amount of Quarterly Reimbursements (if any): $________________________
14. Is employee still receiving weekly compensation benefits?
Yes
No
If Yes, please fill out the following
TYPE OF WEEKLY COMPENSATION
COMPENSATION AMOUNT
Total Disability – Temporary (§34)
a.
$______________________________
Total Disability – Permanent (§34A)
b.
$____________ _ _________________
c.
Partial Disability (§35)
$______________________________
$______________________________
d.
Dependent Coverage (§35A)
e.
Surviving Dependents Coverage (§31)
$______________________________
f.
Other (Specify) ______________________
$______________________________
I hereby certify that the information contained herein is a true accounting of all payments made to the above named employee.
________________________________________________________________
________________________
Signature of Insurer’s Authorized Representative
Prepared Date (mm/dd/yyyy)
_________________________________________________________________________________________
Name & title (Last, First, MI)
I hereby agree to and approve the following reimbursement to be made per the provisions of this agreement.
_______________________________________ __________________
_____________________________________________
Signature for the Office of Legal Counsel
Date (mm/dd/yyyy)
Name & title (Last, First, MI)
I hereby agree to and authorize the following reimbursement to be made per the provisions of this agreement.
_______________________________________ __________________
_____________________________________________
Date (mm/dd/yyyy)
Name & title (Last, First, MI)
Signature for the Office of the Commissioner
Reproduce as needed.
Form 123 - Revised 7/2019