Massachusetts Agreement For Redeeming LiabilityMassachusetts Agreement For Redeeming Liability
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FORM 117

The Commonwealth of Massachusetts
Department of Industrial Accidents

DIA Board #
(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
http://www.mass.gov/dia

AGREEMENT FOR REDEEMING LIABILITY
BY LUMP SUM UNDER G.L. CH. 152
FOR INJURIES OCCURRING ON OR AFTER NOV. 1, 1986

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EMPLOYEE _______________________________ LUMP SUM AMOUNT $______________________
EMPLOYER _______________________________ TOTAL DEDUCTIONS $______________________
INSURER _________________________________ NET TO CLAIMANT $______________________
BOARD NUMBER _________________________ TOTAL PAYMENTS

$______________________
(Weekly benefits plus lump sum)

DATE OF INJURY__________________________
CHECK WHERE APPLICABLE
( )

Liability has been established by acceptance or by standing decision of the Board, the Reviewing Board, or a court of the
Commonwealth and th