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Workers Compensation Mediation Program Mediation Statement - West Virginia
| Workers Compensation Mediation Program Mediation Statement 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 Statement Return to: Offioce f Counsel Attn: Mediation Program Building 1, Room E-317 1900 Kanawha Blvd. E. Charleston, WV 25305-0831 Fax No. 558-6045 Re: Case Name: ______________________________ Claim No. _____: __________________________ Appeal Board Order Date: __________________ Supreme Court No.: _______________________ Statement Submitted on behalf of: _________________________________________________________ Statement Submitted by: Name _____: ____________________________________________________ Address: ________________________________________________________ _________________________________________________________ Telephone: ____________________________ Type of Issues (Check all that apply.) [ ] TTD (Temporary [ ] PPD (Permanent Partial [ ] PTD (Permanent Total [ ] Medical atio[ ] Occunal p Total Disability) Disability) Disability) Benefits Pneumoconiosis [ ] Occupational Hearing [ ] Occupational Disease [ ] Death or Widow Benefits [ ] Other ___________________ Loss (Please specify) Relief sought: __________________________________________________________________ (1) Does this appeal involve a question of first impression? [ ] Yes [ ] No (2) Could this claim involve the Second Injury Reserve? [ ] Yes [ ] No (3) Will the determination of this appeal turn on the interpretation or application of a particular case or statute? Case Name/Statute:_______________________________________ [ ] Yes [ ] No Citation:________________________________________________ (4) Are any related petitions currently pending before the Supreme Court? [ ] Yes [ ] No (If yes, cite the case name and the manner in which it is related on a separate sheet.) (5) Settlement Status:________________________________________________ ___________________ (6) Summary of Partys Position(s): (One additional sheet may be attached.) This Isr To Cetify Thatr this Wokers Compensation Mediation Stat ement Was Mailed to the Clerk of the Supreme Court of Appeals of West Virginia, a CopThey reof Was Served Upon The Mediator, Each Party or Their Counsel of Record and/or the Workers Compensation Division this ____ Day of _____________, 20__ ____________________________________________ Signature of Counsel [ NOTE: Only this form and one additional page is permitted. No attachments.] Mediation Form 3, Mediation Statement [11/6/98]
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