REQUEST FOR MEDIATION IDAHO WORKERS' COMPENSATION Attention: Dennis Burks, Industrial Commission PO Box 83720, Boise, ID 83720-0041 Phone: (208) 334-6000 Fax #: (208) 334-5145 Please complete form in detail: I.C. Claim #__________________ NAME: ________________________________________ SSN: _______________________ Complaint Filed? _____ Yes _____ No REQUEST/REFERRAL DATE: _______________________ REQUESTOR: ________________________________________________________________ PREFERRED LOCATION OF MEDIATION: ____ BOISE ____ IDAHO FALLS ____ COEUR D'ALENE ____ TWIN FALLS ____ LEWISTON ____ POCATELLO ISSUES TO MEDIATE: _________________________________________________________ This box to be completed by mediator: Mediation #: Date and Time Mediation Scheduled: PARTIES AND ADDRESSES CLAIMANT: (If Pro-Se) CLAIMANT ATTORNEY: EMPLOYER: DEFENDANT ATTORNEY SURETY: FORMS\REQMEDIA American LegalNet, Inc. www.FormsWorkflow.com