A Form 117 - Lump Sum Settlement Agreement for Injuries On or After 11/1/1986  pdf format of form-117.pdf
and all of the related forms (including Form 116A - Employer Consent to Lump Sum Agreement , Form 116B - Addendum to Lump Sum Agreement: Vocational Rehabilitation Status , and Form 116C - Lien Disclosure Form ) only require one barcode cover sheet - DIA117 LS Agreement. the parties should bring signed copies for each party and one for the Judge - the Judge's copy must have the bar-code cover sheet. The Judge will stamp all copies. The copy for the file, with the bar-code cover sheet, will be scanned as the official record of the DIA.