Internal Use Only: SUPREME COURT OF APPEALS OF WEST VIRGINIA Workers' Compensation Mediation Program Objection to Mediation Re: Case Name:_____________________________________ Claim No.:______________________________________ Appeal Board Order Date:________________________ Supreme Court No.:______________________________ Receipt of Referral Notice Date:____________________ 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 To 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 ____________________ 20 ____. ____________________________________________ Signature of Counsel 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 2, Objection to Mediation [7/24/98] American LegalNet, Inc. www.USCourtForms.com