Form 114 - Notice Of Change Appearance Of Counsel
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1The Commonwealth of Massachusetts
FORM 114
DIA Board #
Department of Industrial Accidents – Department 114
(If Known):
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
Info. Line 800-323-3249 ext. 7470 in Mass. Outside Mass. - 617-727-4900 ext. 7470
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 COUNSEL HAS BEEN REPLACED BY SUCCESSOR COUNSEL AND IS WITHDRAWING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 7/2013- Reproduce as needed.
Please Print Clearly or Type. Unreadable forms will be returned.
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Parent category: Business