Internal Use Only:

 

SUPREME COURT OF APPEALS OF WEST VIRGINIA
Workers' Compensation Mediation Program
Mediation Conference Report


Date:    _________________________________________

Re:    Case Name: ______________________________
          Claim No.: _______________________________
          Appeal Board Order Date: __________________
          Supreme Court No.: _______________________
          Mediator: ________________________________


Select One:

     [  ]     Settlement reached.

     [  ]     No settlement reached.

     [  ]     Settlement discussions continuing, and a report will be made to Court within ___ (not more than 10 days) days.

     [  ]     The following persons did not attend:

                     _________________________        ________________________
                     (Name)                                             (Reason/Notice)

                     _________________________        ________________________
                     (Name)                                             (Reason/Notice)

                     _________________________        ________________________
                     (Name)                                             (Reason/Notice)

        ________________________      ___________________________
            Date                                                 Signature of Mediator

                                                                             ___________________________
                                                                               Address of Mediator

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 4, Mediation Conference Report [7/24/98]