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    I, _________________________, counsel for _________________________, object to the referral of the above-referenced case to the Workers' 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 Is Certify That this Workers' Compensation Mediation Statement Was Mailed to the Clerk of the Supreme Court of Appeals of West Virginia, a Copy Thereof Was Served Upon Each Party or Their Counsel of Record and/or the Workers' Compensation Division this ____ Day of ____________________ 19 ____.

            ____________________________________________
            Signature of Counsel

Mediation Form 2, Objection to Mediation [7/24/98]