District Of Columbia > Workers Comp
Application For Informal Mediation Conference LB2000 - District Of Columbia
| Application For Informal Mediation Conference Form. This is a District Of Columbia form and can be used in Workers Comp . |
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Government of the District of Columbia Office of Workers' Compensation P.O. Box 56098 Department of Employment Services Washington, D.C. 20011 APPLICATION FOR INFORMAL /MEDIATION CONFERENCE Name of party on whose behalf this application is submitted: _____________________________ Insurer Claim No.: ______________________________________________________________ OWC NO.: _____________________________________________________________________ Date of Injury: __________________________________________________________________ · IF THE PARTY APPLYING FOR INFORMAL CONFERENCE IS REPRESENTED AND THE REPRESENTATIVE HAS NOT ENTERED HIS/HER APPEARANCE, A COPY OF THE REPRESENTATIVE'S AUTHORIZATION MUST BE ATTACHED TO THIS APPLICATION. Claimant's name, address, and phone number:________________________________________ ______________________________________________________________________________ Claimant's representative's name, address, and phone number: ___________________________ ______________________________________________________________________________ Employer's name, address, and phone number: ________________________________________ ______________________________________________________________________________ Carrier's name, address, and phone number: _________________________________________ ______________________________________________________________________________ Employer/Carrier's representative's name, address, and phone number: ____________________ ______________________________________________________________________________ · THE PARTIES ARE ENCOURAGED TO MEET AND DISCUSS ANY AND ALL ISSUES THAT THEY CAN AGREE UPON. ISSUES TO BE DISCUSSED: ___________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Employee's Claims: _____________________________________________________________ ______________________________________________________________________________ Employer/Carrier's Position: ______________________________________________________ ______________________________________________________________________________ _____________________________________________ Signature of Party Requesting Conference LB2000 NOTE: Informal procedures may include informal conferences and mediation conferences; provided, that participation by interested parties in these conferences shall be voluntary. Prior to the Informal Conference, all interested parties must submit all available information to the Office at the earliest possible date. Informal conferences shall be held at the Office unless otherwise designated. When requesting an informal conference outside the Office or by telephone, a statement supporting good cause must be attached to Application. The Associate Director and/or Supervisor will make the final decision. 2000 © American LegalNet, Inc.
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