WC-100 SETTLEMENT MEDIATION REQUEST GEORGIA STATE BOARD OF WORKERS' COMPENSATION REQUEST FOR SETTLEMENT MEDIATION Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury A. IDENTIFYING INFORMATION Name Phone Number County of Injury EMPLOYER Address Phone Number EMPLOYEE Address City City State Zip Code Employee E-mail State Zip Code Employer E-mail INSURER / SELF-INSURER Name Name PARTY AT INTEREST OR SITF Address Name CLAIMS OFFICE Phone Number Address Phone Number City City Party E-mail State Zip Code Claims E-mail State Zip Code ATTORNEY FOR EMPLOYEE/CLAIMANT Address Name ATTORNEY FOR EMPLOYER/INSURER Phone Number Address Name Phone Number City State Zip Code City State Zip Code GA Bar Number Attorney E-mail GA Bar Number Attorney E-mail B. CERTIFICATION 2 By the filing of this Request for Settlement Mediation, all parties certify that they agree to participate in mediation for the purpose of settlement of the above referenced claim(s). The parties hereby further certify that the employer/insurer or self-insurer has obtained, or will obtain by the date of the first setting of this matter, settlement authority based upon a good faith evaluation of this claim, and that all parties are otherwise prepared to go forward. If this claim involves a request for reimbursement from the Subsequent Injury Trust Fund, the parties hereby certify that the Fund has been made aware of the settlement conference or agrees to a settlement conference and has been provided with all necessary documentation. C. ENTRY OF APPEARANCE 2 I hereby certify to the existence of a valid fee contract in compliance with Board Rule 108 or Form WC 102B filed in compliance of Board Rule 102. (A fee contract or Form WC 102B has been filed previously or is attached). D. CERTIFICATE OF SERVICE 2 I hereby certify that I have today sent a copy of this form to all of the parties named above and have sent this form to the State Board of Workers' Compensation, 270 Peachtree St., NW, Atlanta, Georgia 30303-1299. Signature of Employee Representative Date Signature of Employer/Insurer Representative Date Print Name and Telephone Number Here Print Name and Telephone Number Here E-mail E-mail IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS' COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. §34-9-18 AND §34-9-19). WC-100 REVISION 02/2016 100 SETTLEMENT MEDIATION REQUEST American LegalNet, Inc. www.FormsWorkFlow.com