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Workers Compensation Mediation Program Objection To Mediation - West Virginia
| Workers Compensation Mediation Program Objection To Mediation 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 Objection to Mediation Re: Case Name:_____________________________________ Claim No.:______________________________________ Appeal Board Order Date:________________________ Supreme Court No.:______________________________ Receipt of Referral Notice Date:____________________ I, _________________________, counsel for _________________________, object to the referral of the above-referenced case to the Wrkeors Compensation Mediation Program for the following reasons: I, _________________________ submit that these reasons constitute good cause for the removal of the above-referenced case from the Workers Compensation Mediation Program. This notice is filed within fifteen days of receipt of the referral notice as required under Section 3 of the Program Protocols. _______________________________ ___________________________ ___ Date Signature ______________________________ Print Name ______________________________ Address This IsTo Certify Thatr this Wokers Compensation Mediation Staetment Was Mailed to the Clerk of the Supreme Court of Appeals of Wst Ve irginia, a Copy Thereof Was Served Upon Each Party or Their Counsel of Record and/or the Workers Compensation Division this ____Day of ____________________ 20 ____. ____________________________________________ Signature of Counsel 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 2, Objection to Mediation [7/24/98]
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