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Workers Compensation Mediation Program Mediation Conference Report - West Virginia
| Workers Compensation Mediation Program Mediation Conference Report Form. This is a West Virginia form and can be used in Workers Compensation Supreme Court Of Appeals . |
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Internal Use Only: SUPREME COURT OF APPEALS OF WEST VIRGINIA Workers Compensation Mediation Program Mediation Conference Report Date: _________________________________________ Re: Case Name: ______________________________ Claim No.: _______________________________ Appeal Board Order Date: __________________ Supreme Court No.: _______________________ Mediator: ________________________________ Select One: [ ] Settlement reached. [ ] No settlement reached. [ ] Settlement discussions continuing, and a report will be made to Court within ____ (not more than 10 days) days. [ ] The following persons did not attend: _________________________ __________________ ______ (Name) (Reason/Notice) _________________________ __________________ ______ (Name) (Reason/Notice) _________________________ __________________ ______ (Name) (Reason/Notice) ________________________ ___________________________ Date Signature of Mediator ___________________________ Address of Mediator Return to: Office of Counsel Attn: Mediation Program Building 1, Room E-317 1900 Kanawha Blvd. E. Charleston, WV 25305-0831 Fax No. 558-6045 Mediation Form 4, Mediation Conference Report [7/24/98]
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