Form 115 - Third Party Claim / Notice Of Lien 2010

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The Commonwealth of Massachusetts
FORM 115
DIA Board #
Department of Industrial Accidents – Department 115
(If Known):
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470
THIRD PARTY CLAIM / NOTICE OF LIEN
Print Form
PLEASE CHECK ONE ONLY
THIRD PARTY CLAIM
NOTICE OF LIEN
COPIES OF THIS FORM SHOULD BE PROVIDED TO THE INJURED EMPLOYEE AND THE INSURER
IMPORTANT - SEE INSTRUCTIONS AND DEFINITIONS ON REVERSE SIDE
Please Print or Type
1. Name (Business or Individual):
2. Telephone Number:
T
H
I
R
3. Address (No. and Street, City, State, Zip Code):
D
P
A
4. Attorney’s Name and Address (No. and Street, City, State, Zip Code):
5. Attorney’s Telephone Number:
R
T
Y
6. Employee’s Name (Last, First, MI
:
7. Employee’s Social Security Number*:
)
E
M
P
8. Employee’s Address (No. and Street, City, State, Zip Code):
9. Date of Birth (mm/dd/yyyy):
L
O
Y
10. Employer’s Name & Address (No. and Street, City, State, Zip Code):
11. Date of Injury (mm/dd/yyyy):
E
E
12. Insurance Carrier’s Name and Address (No. and Street, City, State, Zip Code):
PLEASE NOTE - if this is a Notice of Lien fill out box 13 only. If this is a Third Party Claim fill out box 14 only.
DO NOT FILL OUT BOTH BOXES. See reverse side of form for definitions and instructions.
13. If this is a lien, please state the nature of services rendered, the statutory basis therefore and the amount thereof:
B
E
N
E
F
I
T
O
R
14. If this is a claim for payment or reimbursement for services provided to the employee, please state the nature of services rendered, the statutory
S
basis therefore and the amount thereof:
E
R
V
I
C
E
15. Preparer’s Signature:
S
I
G
17. Date (mm/dd/yyyy):
16. Preparer’s Name (Please Print):
N
-
*Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents.
Form 115
Revised 7/2010 - Reproduce as needed.
Please Print Legibly or Type - Unreadable forms will be returned.

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