This form is used to waive the $ 650 Appeal of Conference fee. The fee goes toward paying the Impartial Medical Examiner assigned by the Department of Industrial Accidents and the subsequent report.
- Standards And Procedures For § 11A(2) Fee Waiver Requests
- Poverty Guidelines 2013
- Form 136 - Affidavit of Indigence and Request for Waiver of Sec. 11A (2) Fees
Standards and Procedures For § 11A(2) Fee Waiver Requests
- Requests for waivers of the MGL c. 152, § 11A(2) impartial medical examination fees must be made by filing a Departmental Form 136 with the Director, on or before ten (10) calendar days following the filing of an appeal of a conference order or allowance of a late appeal pursuant to MGL c. 152, § 10A. Form 136 waiver requests not filed within the ten-day period will be considered only when warranted.
- A party's Form 136 waiver request may be granted after applying the standards set forth in SJC Rule 3:10: receipt of one of the designated types of public assistance; having an annual income after taxes of 125% or less of the current poverty threshold; and/or consideration of a party's available funds or special circumstances. The appeal of any party whose waiver request is granted shall be deemed perfected.
- If the Form 136 waiver request is denied, the Director shall render a Notice of Denial setting forth the reason(s) for the denial. Such Notice shall constitute the Commissioner's final determination, unless the party timely seeks reconsideration.
- A party whose Form 136 waiver request is denied may perfect the appeal by paying the impartial medical examination fee within ten (10) calendar days following the filing date of the Director's final determination, provided the Form 136 request was timely filed. Remittance of the fee in all other instances shall be allowed only when warranted.
- Insurers shall reimburse the Department for fees waived and paid by the Department on behalf of an indigent party who prevails on, adjusts, or lump sums a claim.
- As set out below, a party requesting a waiver shall submit documentation with Form 136 to verify information on the form. Failure to submit the required documentation may result in denial of the request. When warranted, alternative forms of verification may be allowed or required by the Director.
Bank Accounts, Certificates of Deposit, and Savings Accounts.Copies of bank books or statements that show the balance within 45 days of the date of the filing of Form 136. For joint bank accounts, the entire balance shall be indicated as an asset, unless the applicant can demonstrate other than joint ownership.
Basic Living Costs.
- Shelter costs: canceled checks, money order receipts, and/or monthly or other periodic mortgage statements or copies of leases or rental agreements.
- Food and clothing costs: receipts or affirmed statements.
- Utility, telephone, heat, water, and sewer costs: monthly/periodic bills.
- Health insurance premiums; health care treatment/services essential for treatment: copies of paid medical bills, health insurance premium payments or bills.
- Transportation costs: copies of paid bills, receipts, or statements for transportation costs, including those related to motor vehicle loans and insurance.
- Education and support payments: copies of canceled checks or receipts showing the amount and date of the payment and to whom paid.
Income (wages, salary, tips, and other earnings; self-employment income).Pay stubs, pay envelopes, a written statement signed by an employer, W-2's, or 1099's showing the gross wages (including tips, if applicable) and deductions. For self-employment income, business records showing total income and total business expenses (records of bank deposits; wages, social security and other taxes paid, etc.) associated with the gross income earned for the three most current months.
Income from Other Sources.
- Workers' compensation, social security, long- or short-term disability, unemployment, and welfare benefits: copies of benefit payment checks, award letter(s), or statement(s) from the agency/person making the payment that indicates the amount and frequency of the payment. For workers' compensation, also copies of the order, agreement, hearing decision; and, where applicable, copies of any wage statements filed with the insurer pursuant to MGL c. 152, § 11D.
- Pensions: retirement fund statements and other related documents.
- Dividends and interest: copy of the most recent bank or other financial statement showing yearly/ periodic receipts.
- Rental or other realty income: copies of rental receipts or other statements.
- Other sources: copies of formal statements indicating amount and dates.
Motor Vehicles - Equity Value.Equity value: fair market value (price of the vehicle on the open market - verified by advertisements, book value) minus the balance of any liens/loans (verified by payment book(s) or statement(s) from the lending institution). All vehicles must be listed. Equity value in excess of $1500 is countable, provided the equity is reasonably convertible to cash and the vehicle is not needed for employment.
Real Property - Equity Value.
Equity value: fair market value (price on the open market - verified by assessment or appraisal documents) less encumbrances (verified by copies of loan instruments or other documents evidencing the outstanding loan balance). The equity value of all real property owned shall be countable, provided it is reasonably convertible to cash, for example, by the availability of an equity line of credit.
Securities (stocks, bonds, futures, contracts, debentures, mutual/other funds, etc.)
Copies of statements from the individual, corporation, licensed stockbroker, bank or government agency that issued the security; a current daily newspaper clipping showing the date and closing bid price; a bank or other financial institution statement verifying current security value; or documentation from a current financial publication.