Form 114 "Notice of Change/Appearance of Counsel" - Massachusetts

What Is Form 114?

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 114 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 114 "Notice of Change/Appearance of Counsel" - Massachusetts

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The Commonwealth of Massachusetts
FORM 114
DIA Board #
Department of Industrial Accidents – Department 114
(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
NOTICE OF CHANGE / APPEARANCE OF COUNSEL
THIS FORM MUST BE FILED WHEN AN ATTORNEY APPEARS AS LEGAL COUNSEL FOR
THE FIRST TIME OR A CHANGE OF COUNSEL HAS OCCURRED. ALL PARTIES MUST BE NOTIFIED.
PLEASE NOTE - WHEN AN ATTORNEY LEAVES A FIRM AND ANOTHER ATTORNEY IN THAT FIRM TAKES
OVER ACTIVE CASES, AN APPEARANCE OF COUNSEL MUST BE FILED FOR EACH MATTER.
Please Print or Type
1. Employee’s Name (Last, First, MI
2. Employee’s Social Security Number*:
:
)
E
M
P
3. Employee’s Address (No. and Street, City, State, Zip Code):
4. Date of Injury (mm/dd/yyyy):
L
O
Check box if this is a new address
Y
5. Employer’s Name & Address (No. and Street, City, State, Zip Code):
E
E
Check box if this is a new address
6. Insurance Carrier’s Name:
Yes
No
7. Self-Insured?:
&
If Yes - Self Insurer #:
8. Insurance Carrier’s Address (No. and Street, City, State, Zip Code):
I
N
S.
9. PLEASE ENTER MY APPEARANCE FOR:
Employee
Insurer
Third Party
Other (Specify) ______________________________
-
10. EMPLOYEE HAS DISCHARGED ME AS COUNSEL
11. COUNSEL HAS BEEN REPLACED BY SUCCESSOR COUNSEL AND IS WITHDRAWING
FROM REPRESENTATION OF:
Employee
Insurer
Third Party
Other (Specify) ________________
Attach Appearance of Successor Counsel
12. COUNSEL FOR:
Employee
Insurer
Third Party
Other (Specify) ________________________
REQUESTS PERMISSION TO WITHDRAW PURSUANT TO 452 C.M.R. 1.18 (3)
13. APPROVED BY: ___________________________________
________________________
(Name)
(Title)
__________________________________________________________________
_____________________________
(Signature) ON BEHALF OF THE DIVISION OF DISPUTE RESOLUTION
(Date - mm/dd/yyyy)
14. Attorney’s Name & Address:
Check box if this is a new address
15. Attorney’s Board of Bar Overseer’s Number:
16. Attorney’s Telephone Number:
17. Attorney’s Signature:
18. Date Prepared (mm/dd/yyyy):
-
*Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents.
Form 114
Revised 7/2019 - Reproduce as needed.
Please Print Clearly or Type. Unreadable forms will be returned.
The Commonwealth of Massachusetts
FORM 114
DIA Board #
Department of Industrial Accidents – Department 114
(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
NOTICE OF CHANGE / APPEARANCE OF COUNSEL
THIS FORM MUST BE FILED WHEN AN ATTORNEY APPEARS AS LEGAL COUNSEL FOR
THE FIRST TIME OR A CHANGE OF COUNSEL HAS OCCURRED. ALL PARTIES MUST BE NOTIFIED.
PLEASE NOTE - WHEN AN ATTORNEY LEAVES A FIRM AND ANOTHER ATTORNEY IN THAT FIRM TAKES
OVER ACTIVE CASES, AN APPEARANCE OF COUNSEL MUST BE FILED FOR EACH MATTER.
Please Print or Type
1. Employee’s Name (Last, First, MI
2. Employee’s Social Security Number*:
:
)
E
M
P
3. Employee’s Address (No. and Street, City, State, Zip Code):
4. Date of Injury (mm/dd/yyyy):
L
O
Check box if this is a new address
Y
5. Employer’s Name & Address (No. and Street, City, State, Zip Code):
E
E
Check box if this is a new address
6. Insurance Carrier’s Name:
Yes
No
7. Self-Insured?:
&
If Yes - Self Insurer #:
8. Insurance Carrier’s Address (No. and Street, City, State, Zip Code):
I
N
S.
9. PLEASE ENTER MY APPEARANCE FOR:
Employee
Insurer
Third Party
Other (Specify) ______________________________
-
10. EMPLOYEE HAS DISCHARGED ME AS COUNSEL
11. COUNSEL HAS BEEN REPLACED BY SUCCESSOR COUNSEL AND IS WITHDRAWING
FROM REPRESENTATION OF:
Employee
Insurer
Third Party
Other (Specify) ________________
Attach Appearance of Successor Counsel
12. COUNSEL FOR:
Employee
Insurer
Third Party
Other (Specify) ________________________
REQUESTS PERMISSION TO WITHDRAW PURSUANT TO 452 C.M.R. 1.18 (3)
13. APPROVED BY: ___________________________________
________________________
(Name)
(Title)
__________________________________________________________________
_____________________________
(Signature) ON BEHALF OF THE DIVISION OF DISPUTE RESOLUTION
(Date - mm/dd/yyyy)
14. Attorney’s Name & Address:
Check box if this is a new address
15. Attorney’s Board of Bar Overseer’s Number:
16. Attorney’s Telephone Number:
17. Attorney’s Signature:
18. Date Prepared (mm/dd/yyyy):
-
*Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents.
Form 114
Revised 7/2019 - Reproduce as needed.
Please Print Clearly or Type. Unreadable forms will be returned.