ADMINISTRATIVE BULLETIN
To: All Parties
From: Omar Hernández, Senior Judge
Re: Form 19 and Form 113
Date: June 24, 2014
The Department of Industrial Accidents, in conjunction with the MBA Workers’ Compensation Section, is pleased to announce the creation of a new standardize form for Section 19 agreements as well as updating the current Form 113, Agreement to Pay Compensation.
The development of the new Section 19 agreement was long overdue and it brings uniformity and provides for relevant information that often times was missing. The Form 113 was changed to include language, similar to the Form 19, indicating whether or not the agreement closes out the current litigation and if not, what issues remain in dispute. Please be advised, when submitting a Form 19 Section 19 Agreement, please create a bar code using the “DR-Sec. 19 Agree” coversheet.
Effective immediately, please use these forms as they are now available on the DIA website:
Form 19 Section 19 Agreement – created 6/2014
http://www.mass.gov/lwd/workers-compensation/wc-pubs/forms/form-list-numbered/form-19.pdf
Form 113 Agreement to Pay Compensation – revised 6/2014
http://www.mass.gov/lwd/workers-compensation/wc-pubs/forms/form-list-numbered/form-113.pdf