West Virginia > Supreme Court Of Appeals > Workers Compensation
Workers Compensation Mediation Program Mediation Conference Request - West Virginia
| Workers Compensation Mediation Program Mediation Conference Request Form. This is a West Virginia form and can be used in Workers Compensation Supreme Court Of Appeals . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Internal Use Only: SUPREME COURT OF APPEALS OF WEST VIRGINIA Workers Compensation Mediation Program Mediation Conference Request Re: Case Name: ___________________________________ Claim No.: ___________________________________ Appeal Board Order Date: _____________________ Supreme Court No.: ___________________________. Because the parties in the above-referen cascede agree that a settlement conference could be helpful, the parties request the above-referencd cease be included in the Courts Workers Compensation Mediation Program. Select One. [ ] The parties will be making private mediation arrangements and will notify the Court of these arrangements within thirty (30) days of the filing of this request with the Court. [ ] The parties request that the Court schedule a mediation conference. If this option is selected, additional information on the program will be provided. Such information is available on the Cos Wurt EB site (http://www.state.wv.us/wvsca). ___________________ _____________________ ______ ______________ Counsel for Claimant Counsel for the Employer Counsel for Division ___________________ _____________________ ______ ______________ Street Address Street Address Street Address ___________________ _____________________ ______ ______________ City, State, Zip City, State, Zip City, State, Zip ___________________ _____________________ _____ _______________ Telephone Number Telephone Number Telephone Number ___________________ _____________________ _____ _______________ Fax Number Fax Number Fax Number 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 1, Mediation Conference Request [7/24/98]
|
|||||||
