Workers Compensation Mediation Program Mediation Conference Report
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Workers Compensation Mediation Program Mediation Conference Report Form. This is a West Virginia form and can be use in Workers Compensation Supreme Court Of Appeals.
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Tags: Workers Compensation Mediation Program Mediation Conference Report, West Virginia Supreme Court Of Appeals, Workers Compensation
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]
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