Get Form 117

Filling out Form 117 online is a vital step in the process of redeeming liability under Massachusetts workers’ compensation laws. This guide provides a clear, step-by-step approach to help users navigate the form easily and accurately.

Follow the steps to complete Form 117 online successfully.

1. Click the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by entering the employee's name in the designated field at the top of the form.
3. Next, input the lump sum amount that is being agreed upon in the appropriate field.
4. Provide the employer's name and indicate any known board number if applicable.
5. Enter the insurer's name and detail the total deductions that will be taken from the lump sum amount.
6. Fill in the date of injury to ensure the form is accurately dated.
7. Indicate whether liability has been established by checking the appropriate box.
8. Select options regarding the insurer’s agreement to pay outstanding medical bills by checking the relevant box.
9. Complete the section on deductions, specifying the amounts and names of parties to whom payments will be made.
10. Provide employee medical information, including age, number of dependents, average weekly wage, and social security number.
11. Detail any present medical conditions and third-party actions involved.
12. Write a brief history outlining the case and justifying why the settlement is in the employee's best interest.
13. Review all entered information for accuracy before proceeding.
14. Save your changes and download or print the completed form for submission.

Start filling out your Form 117 online today to ensure a smooth processing experience.