Virginia > Workers Compensation
Request For Mediation - Virginia
| Request For Mediation Form. This is a Virginia form and can be used in Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Virginia Workers' Compensation Commission Request for Mediation VWC/JCN File Number: _________________________ Date of Injury: _____________________________ Person Requesting Mediation: Claimant Claims Administrator Claimant Attorney Claims Administrator Attorney Other: __________________________________ Name: ______________________________ Phone #: (_____) _____________ Fax #: (_____) _______________ Address: (Number, Street, Apt., City, State and Zip) _____________________________________ _____________________________________ Describe the issue that you believe should be the subject of the mediation: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ I consent to mediation of this matter by an employee of the Virginia Workers' Compensation Commission. I understand if one of the other parties objects to this request the matter will not be referred for mediation. Signature: ___________________________ Mail or Fax this form to: Mediation Scheduler Virginia Workers' Compensation Commission 1000 DMV Drive Richmond, Virginia 23220 FAX: 804-367-9740 Date: _________________ American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
