BEFORE THE ARKANSAS WORKERS' COMPENSATION COMMISSION CLAIM NO. _______________ _________________________________________, EMPLOYEE _________________________________________, EMPLOYER _________________________________________, CARRIER CLAIMANT RESPONDENT 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