Form 117 "Lump Sum Settlement Agreement for Injuries on or After 11/1/1986" - Massachusetts

What Is Form 117?

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 117 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 117 "Lump Sum Settlement Agreement for Injuries on or After 11/1/1986" - Massachusetts

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FORM 117
The Commonwealth of Massachusetts
DIA Board #
Department of Industrial Accidents
(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
AGREEMENT FOR REDEEMING LIABILITY
Page 1 of 2
BY LUMP SUM UNDER G.L. CH. 152
Please Print or Type
FOR INJURIES OCCURRING ON OR AFTER NOV. 1, 1986
EMPLOYEE _______________________________ LUMP SUM AMOUNT $______________________
EMPLOYER _______________________________ TOTAL DEDUCTIONS $______________________
INSURER _________________________________ NET TO CLAIMANT $______________________
BOARD NUMBER _________________________ TOTAL PAYMENTS
$______________________
(Weekly benefits plus lump sum)
DATE OF INJURY__________________________
CHECK WHERE APPLICABLE:
( )
Liability has been established by acceptance or by standing decision of the Board, the Reviewing Board, or a court of the
Commonwealth and this settlement shall not redeem liability for the payment of medical benefits and vocational
rehabilitation benefits with respect to such injury.
( )
Liability has NOT been established by standing decision of the Board, the Reviewing Board, or a court of the
Commonwealth and this settlement shall redeem liability for the payment of medical benefits and vocational
rehabilitation benefits with respect to such injury.
( )
In addition to the lump-sum, the insurer agrees to pay all outstanding reasonable and related medical bills incurred as of
this date.
( )
The employee is currently receiving a cost-of-living adjustment.
Based on the employee’s age ______ and life expectancy of _____ years, this net settlement of $ _____________
( )
represents payment to the employee of $ __________ per month for life pursuant to Sciarotta v. Bowen, 837 F.2d. 135
(3d Cir., 1988).
DEDUCTIONS: From the lump-sum amount as stated above, the amount(s) listed below will be deducted and paid directly to the following parties:
NAME
ADDRESS
1. $_____________________ ________________________________________
________________________________________
Attorney’s Fee
2. $_____________________ ________________________________________
________________________________________
Attorney’s Expenses
(Please attach documentation)
3. $_____________________ ________________________________________
________________________________________
Liens
(Please attach discharges)
4. $_____________________ ________________________________________
________________________________________
Inchoate Rights
(Please specify release)
5. $_____________________ ________________________________________
________________________________________
6. $_____________________ ________________________________________
________________________________________
7. $_____________________ ________________________________________
________________________________________
(OVER)
Form 117 – Revised 7/2019- Reproduce as needed.
FORM 117
The Commonwealth of Massachusetts
DIA Board #
Department of Industrial Accidents
(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
AGREEMENT FOR REDEEMING LIABILITY
Page 1 of 2
BY LUMP SUM UNDER G.L. CH. 152
Please Print or Type
FOR INJURIES OCCURRING ON OR AFTER NOV. 1, 1986
EMPLOYEE _______________________________ LUMP SUM AMOUNT $______________________
EMPLOYER _______________________________ TOTAL DEDUCTIONS $______________________
INSURER _________________________________ NET TO CLAIMANT $______________________
BOARD NUMBER _________________________ TOTAL PAYMENTS
$______________________
(Weekly benefits plus lump sum)
DATE OF INJURY__________________________
CHECK WHERE APPLICABLE:
( )
Liability has been established by acceptance or by standing decision of the Board, the Reviewing Board, or a court of the
Commonwealth and this settlement shall not redeem liability for the payment of medical benefits and vocational
rehabilitation benefits with respect to such injury.
( )
Liability has NOT been established by standing decision of the Board, the Reviewing Board, or a court of the
Commonwealth and this settlement shall redeem liability for the payment of medical benefits and vocational
rehabilitation benefits with respect to such injury.
( )
In addition to the lump-sum, the insurer agrees to pay all outstanding reasonable and related medical bills incurred as of
this date.
( )
The employee is currently receiving a cost-of-living adjustment.
Based on the employee’s age ______ and life expectancy of _____ years, this net settlement of $ _____________
( )
represents payment to the employee of $ __________ per month for life pursuant to Sciarotta v. Bowen, 837 F.2d. 135
(3d Cir., 1988).
DEDUCTIONS: From the lump-sum amount as stated above, the amount(s) listed below will be deducted and paid directly to the following parties:
NAME
ADDRESS
1. $_____________________ ________________________________________
________________________________________
Attorney’s Fee
2. $_____________________ ________________________________________
________________________________________
Attorney’s Expenses
(Please attach documentation)
3. $_____________________ ________________________________________
________________________________________
Liens
(Please attach discharges)
4. $_____________________ ________________________________________
________________________________________
Inchoate Rights
(Please specify release)
5. $_____________________ ________________________________________
________________________________________
6. $_____________________ ________________________________________
________________________________________
7. $_____________________ ________________________________________
________________________________________
(OVER)
Form 117 – Revised 7/2019- Reproduce as needed.
AGREEMENT FOR REDEEMING LIABILITY BY LUMP SUM SETTLEMENT
(Page 2 of 2)
EMPLOYEE MEDICAL INFORMATION:
Age ______ No. of Dependents _____ Average Weekly Wage $______________ Compensation Rate $_________________
Social Security No.*: ______-____-_____ Occupation _______________________ Educational Background _______________
On Social Security: YES ( ) NO ( )
On Public Employee Disability Retirement: YES ( ) NO ( )
DIAGNOSIS ___________________________________ PRESENT MEDICAL CONDITION _________________________
______________________________________________
________________________
Present Work Capacity: ______________________________
Third Party Action _____________________________
PLEASE GIVE A BRIEF HISTORY OF THE CASE AND INDICATE WHY THE SETTLEMENT IS
IN THE EMPLOYEE’S BEST INTEREST (Specify all allocations):
(Please attach a separate sheet if necessary.)
Received of ____________________________________________________________ the Lump Sum of _____________________________
____________________________________ dollars and ________________ cents ($___________________)
me under the Workers’
This payment is received in redemption of the liability of all weekly payments now or in the future due
Compensation Act, for all injuries received by_____________________________________________________________________________
on or about ____________________________________ while in the employ of _________________________________________________
____________________________________________. I fully understand that after all of the deductions herein I will receive
$______________________________. I am fully satisfied with and request approval of this settlement. This agreement
has been translated for me into my native language of _____________________________________.
SIGNATURE
ADDRESS
ZIP CODE
CLAIMANT:
CLAIMANT’S
COUNSEL:
INSURER’S
COUNSEL:
Signed this _____________________ day of __________________________________ 20____
*Disclosure of Social Security Number is Voluntary. It will aid in the processing of this document.
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