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-referenced case agree that a settlement conference could be helpful, the parties request the above-referenced case be included in the Court's 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 Court's WEB 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

Mediation Form 1, Mediation Conference Request [7/24/98]