Fill and Sign the Lump Sum Agreement Template Form

     Employee Name:       Board #-       The employee has returned to continuous employment for a period of six months or more. The employee has completed an approved rehabilitation plan. Signed this                                                       Consented to:       Date:       OEVR Comments:             Order/Decision:       FORM 116B The Commonwealth of Massachusetts DIA Board # Department of Industrial Accidents - Department 116B 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 (If Known): ADDENDUM TO LUMP SUM SETTLEMENT AGREEMENT PURSUANT TO M.G.L. c. 398 ~ 75 OF THE ACTS OF 1991, EFFECTIVE DECEMBER 23,1991 - VOCATIONAL REHABILITATION STATUS PART A Written consent of the Office of Education and Vocational Rehabilitation is not required as a condition precedent to the validity of the Lump Sum Agreement where: PLEASE CHECK ONE: No determination has been made with respect to the employee's suitability for Vocational Rehabilitation pursuant to G.L. c. 152, § 30G. The employee has been found unsuitable by the Office of Education and Vocational Rehabilitation for Vocational Rehabilitation pursuant to G.L. c. 152, § 30G. day of 20 SIGNATURE ADDRESS CLAIMANT CLAIMANT'S COUNSEL INSURER'S PART B Where the employee has been found suitable for Vocational Rehabilitation services pursuant to G.L. c. 152, § 3OG and has not returned to continuous employment for a period of six or more months or completed an approved rehabilitation plan, the Office of Education and Vocational Rehabilitation may nevertheless consent in writing to the Lump Sum, or an administrative judge or administrative law judge, by order or decision may authorize such agreement. G.L. c. 152, § 48 (3). ''Any employee who receives a [lump sum] amount in violation of 1§ 48(3)] shall have the right to re-open his or her claim for compensation.'' 1L PART C Please note that when liability is established, the Lump Sum Agreement shall not redeem liability for the payment of medical benefits or vocational rehabilitation benefits with respect to such injury. An employee may seek vocational rehabilitation within two (2) years of perfection of the lump sum settlement. G.L. c. 152, § 48 (2). Office of Education and Vocational Rehabilitation Administrative Judge/Administrative Law Judge Reproduce as needed. FORM 116B Revised 8/2001