This form must be filed at the lump sum conference. It is not sent in with the Form 116 (Request for Lump Sum Conference). It must be signed by the claimant, the claimant's counsel, and the counsel for the insurer.

When the claimant has been found suitable for vocational rehabilitation this form must also be signed by the Office of Education and Vocational Rehabilitation.

Print Form 116B  pdf format of form-116B.pdf

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