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:

3. Address (No. and Street, City, State, Zip Code):

4. Attorney’s Name and Address (No. and Street, City, State, Zip Code):

5. Attorney’s Telephone Number:

6. Employee’s Name (Last, First, MI

7. Employee’s Social Security Number*:

)

8. Employee’s Address (No. and Street, City, State, Zip Code):

9. Date of Birth (mm/dd/yyyy):

10. Employer’s Name & Address (No. and Street, City, State, Zip Code):

11. Date of Injury (mm/dd/yyyy):

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:

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

basis therefore and the amount thereof:

15. Preparer’s Signature:

17. Date (mm/dd/yyyy):

16. Preparer’s Name (Please Print):

*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.