Fill and Sign the Agreement under 37 37a for Workers Compensation Massachusetts Form

NEGOTIATED FULL & FINAL                                                                              or 37A . $       13. Amount of Quarterly Reimbursements (if any): $       No If Yes, please fill out the following Total Disability - Temporary (§34) Total Disability - Permanent (§34A) Partial Disability (§35) Dependent Coverage (§35A) Surviving Dependents Coverage (§3 1) Other (Specify) $       $       $       $       $             $                                           FORM 123 The Commonwealth of Massachusetts DIA BOARD NO.Department of Industrial Accidents - Department 123 600 Washington Street - 7th Floor, Boston, Massachusetts 02111 Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470 http://www.state.ma.us/dia §37 or §37A Claim AGREEMENT UNDER SECTION 37 or 37A Please print or type. 1. Employee's Name (Last, First, Ml): E M P L O Y E E 2. Home Address (No. & Street, City, State, Zip Code): 3. Employer's Name: 4. Employer's Address (No. & Street, City, State, Zip Code): I N S U R E R 5. Insurance Carrier's Name: 6. Insurance Company Address: 7. Name & Address of Person Able to Verify Information: 8. Telephone Number: 9. Paid Through (mm/dd/yyyy): 10. First Date of Disability (mm/dd/yyyy): 11. If Employee Died, Enter Date of Death: 12. Total Amount to be reimbursed under Section 37 (Check all that apply to this agreement) 14. Is employee still receiving weekly compensation benefits? TYPE OF WEEKLY COMPENSATION Yes COMPENSATION AMOUNT a. b. C d. e. f. 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. Date (mm/dd/yyyy) Name & title (Last, First, MI) Signature for the Office of Legal Counsel I hereby agree to and authorize the following reimbursement to be made per the provisions of this agreement. Signature for the Office of the Commissioner Date (mm/dd/yyyy) Name & title (Last, First, MI) Reproduce as needed. Form 123 - Revised 8/2001