1) After you file this claim it will be scheduled for Conciliation in the Boston Office unless the parties agree in writing, at the time of the filing, that it is to be adjudicated at a specified regional office.

2) A claim requesting reimbursement under M.G.L. c. 152, § 37 and § 37A shall be made on Form 122 and it shall be accompanied by both a certificate stating that it was served on the Office of Legal Counsel, and by a petition which sets forth and documents items which include, but are not limited to, the following:

a) Employee's job description and duties; educational, military, and employment history; and, vocational training prior to the "subsequent impairment" (i.e., compensable personal injury for which petitioner seeks G.L. c. 152, §§ 37/37A reimbursement; also known as "second injury.")

b) Evidence of employer's knowledge of employee's pre-existing physical impairment due to a previous accident, disease or congenital condition as evidenced by such documents as a job application, a pre-employment physical report, or by the employer's affidavit attesting that the employer knew of the impairment not later than 30 days after the date of employment, or (for injuries occurring prior to 12/23/91) by medical records which existed prior to the date of the subsequent impairment.

c) Evidence that a known pre-existing physical impairment was, or was likely to be, a hindrance or obstacle to employment (i.e., medical records evidencing permanent physical restrictions, documented job modifications or accommodations which employer made on behalf of employee).

d) All medical records pertaining to the subsequent impairment including attending physicians reports, insurance medical examinations, and DIA impartial physician report.

e) From the compensation claim involving the second injury, copies of all DIA documents which substantiate the reimbursement which the petitioner seeks, such as:

                1) Employee Claim Form (110)

                2) First Report of Injury

                3) Agreements(s) to Compensation

                4) Conference Orders, Hearing Decisions and Lump Sum Agreement

f) Indemnity record for all reimbursable compensation paid after the 104th week from the date of the onset of disability or death that clearly identify the claimant, the section under which compensation was paid, the dates for which payment was made, and the amount of weekly compensation.

g) Medical bills paid for all related reimbursable medical treatment received by the employee after the 104th week from the date of the onset of disability.(Computer printouts which clearly identify the claimant, the service providers, and the date of service constitute satisfactory documentation).

h) A description of the subsequent impairment which includes an authoritative medical statement as to how the subsequent impairment is substantially greater (by the combined effects of such impairment and subsequent personal injury) than the disability that would have resulted from the subsequent personal injury alone, or that the subsequent injury was caused by the pre-existing impairment, and, if death results from the subsequent injury, that the death would not have occurred except for such pre-existing physical impairment.

Print -   Form 122  pdf format of form-122.pdf
Request For Section 37 or 37A Proceeding

Print  -   Form 123 - Agreement Under Section 37 or 37A  pdf format of Form 123 - Agreement Under Section 37 or 37A