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SUPREME COURT OF APPEALS OF WEST VIRGINIA
Workers' Compensation Mediation Program
Mediation Statement
| 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 |
Re: Case Name: ______________________________
Claim No.:
_______________________________
Appeal Board Order Date:
__________________
Supreme Court No.:
_______________________
Statement Submitted on behalf
of:
_________________________________________________________
Statement Submitted by:
Name
_________________________________________________________
Address
________________________________________________________
_________________________________________________________
Telephone
________________________
Type of Issues (Check all that apply.)
[ ] TTD (Temporary [ ]
PPD (Permanent Partial [ ] PTD (Permanent Total
[ ] Medical
[ ] Occupational
Total
Disability)
Disability)
Disability)
Benefits
Pneumoconiosis
[ ] Occupational Hearing [ ] Occupational
Disease [ ] Death or Widow Benefits
[ ] Other ___________________
Loss
(Please specify)
Relief sought: __________________________________________________________________
(1) Does this appeal involve a question of first
impression? [ ] Yes [ ] No
(2) Could this claim involve the Second Injury Reserve? [ ] Yes [ ] No
(3) Will the determination of this appeal turn on the interpretation or application of a
particular case or statute?
Case
Name/Statute:_______________________________________ [
] Yes [ ] No
Citation:________________________________________________
(4) Are any related petitions currently pending before the Supreme Court? [ ] Yes [ ] No
(If yes, cite the case name and the manner in which it is related on a separate sheet.)
(5) Settlement
Status:____________________________________________________________________________
(6) Summary of Party's Position(s): (One additional sheet may be attached.)
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 The Mediator, Each Party
or Their Counsel of Record and/or the Workers' Compensation Division this ____ Day of
____________________ 19 ____.
____________________________________________
Signature of
Counsel
[ NOTE: Only this form and one additional page is permitted. No attachments.]
Mediation Form 3, Mediation Statement [11/6/98]