OKLAHOMA WORKERS' COMPENSATION COMMISSION MEDIATION SYSTEM MEDIATION CONFERENCE REPORT MUST be completed. Please type or print legibly. Claim for Compensation (i.e. CC-Form-3 or CC-Form-3B) on File With the Workers' Compensation Commission? G Yes (Commission File No. ____________________) G No Claimant/Injured Worker (Full Name): _____________________________________________________ Respondent/Employer (Name): ____________________________________________________________ Insurer (Name):__________________________________________________________________________ Check One: G Mediation By Mutual Agreement of the Parties (i.e. No Commission Order of Referral to Mediation) G Commission Ordered Referral to Mediation 1. Mediation conference date:________________________________________________ 2. Mediation conference location (city and county): _____________________________ 3. Mediation conference length ______ hours ______minutes. 4. The case was (circle one letter): a. settled in full; b. not settled; c. settled in part (circle appropriate number): (1) parties reached agreement on one or more issues or claims; (2) case settled as to some parties, but not all parties. ____________________________________ Mediator _________________________________ Date (Send original to Workers' Compensation Commission Counselor Division, 1915 N. Stiles Ave. Oklahoma City, OK 73105) Revised 2-8-17 American LegalNet, Inc. www.FormsWorkFlow.com