South Dakota > Workers Compensation
Mediation Request Form - South Dakota
| Mediation Request Form Form. This is a South Dakota form and can be used in Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
MEDIATION REQUEST FORM Date: _________________________________ By completing this form and sending it to the Department, you are requesting a mediation. You will be contacted by phone to schedule the mediation within two to three weeks. Name: _______________________________ Address: _______________________________ _______________________________ Social Security No: _____________________ Date of Injury: _____________________ Daytime Phone No: _____________________ (where you can be reached to schedule the mediation) Please list all of the issues you would like to discuss during the mediation. In addition, attach any documents you have to support your position, including any medical records. ________________________________________________________________________ ____ ________________________________________________________________________ ____ ________________________________________________________________________ ____ ________________________________________________________________________ ____ ________________________________________________________________________ ____ ________________________________________________________________________ ____ ________________________________________________________________________ ____ ________________________________________________________________________ ____ ________________________________________________________________________ ____ ________________________________________________________________________ ____ ________________________________________________________________________ ____ ________________________________________________________________________ ____ ________________________________________________________________________ ____ Please send this form to: South Dakota Department of Labor Division of Labor and Management 700 Governors Dr. Pierre, SD 57501 Phone: (605) 773-3681 Fax: (605) 773-4211
|
|||||||
