BEFORE THE ARKANSAS WORKERS’ COMPENSATION COMMISSION CLAIM NO. _______________ _________________________________________, EMPLOYEE CLAIMANT _________________________________________, EMPLOYER RESPONDENT _________________________________________, CARRIER RESPONDENT REPORT OF MEDIATION CONFERENCE The (check one) “ telephone “ in-person conference on _______________________, was attended by: Claimant (“ Yes “ No) Respondent Employer (“ Yes “ No) Respondent Carrier (“ Yes “ No) Claimant’s attorney (“ Yes “ No) Respondent’s attorney (“ Yes “ No) Other(s): ______________________________________________________________, and the following issues were fully resolved by the parties in the presence of the undersigned mediator: “ None, or (list resolved issues) A copy of this Report is placed in the case file and mailed to each party, who is to make any written objection as to its accuracy within ten (10) days to the Clerk of the Commission, at P. O. Box 950, Little Rock, AR 72203-0950. _____________________________________________ Mediator Date: R cc: Claimant / Respondent(s) Form AR-R (Rev.1-1-2001) American LegalNet, Inc. www.FormsWorkFlow.com