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