+ WC-184 WC-184 (01-18) AI MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS222 COMPENSATION 3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102 -0058 www.labor.mo.gov/DWC REQUEST FOR MEDIATION 1. INJURY NUMBER - Note: This form must be completed in its entirety and must be typed or hand printed in black ink . Please submit this form to the appropriate adjudicat ion office. 2. Date of Injury 3. Employee 4. Address of Employee 5. Case Venue 6. Attorney for Employee 7. Address of Employee222s Attorney 8. Second Injury Fund Involved Yes No Email Address: 9. Attorney for Employer/Insurer 10. Address of Employer/Insurer Attorney 11. Name of Second Injury Fund Attorney Email Address: 12. Insurance Company and/or Third Party Administrator 13. Address of Insurance Company or Third Party Administrator, if known 14. P arty Requesting the Mediation 15. Please briefly state your reason(s) for requesting the mediation: CERTIFICATE OF SERVICE I, the undersigned, certify that a copy of this request has been mailed or hand - de livered to all attorneys and/or parties of record on this day of , 20 . Attorney222s signature Bar Number Date Attorney222s Name (Printed) Address P hone Number An administrative law judge cannot act as an attorney for any party or give any specific legal advice to any party regarding the case. An administrative law judge shall approve a settlement agreement as long as: The settlement is not the result of undue influence or fraud; The employee fully understands his or her rights and benefits; The employee voluntarily agrees to accept the terms of the agreement; and The settlement is in accordance with the rights of the parties. DIVISION USE ONLY COMPLETED BY DIVISION OF WORKERS222 COMPENSATIONApproved Date Please visit our website at www.labor.mo.gov/DWC if you have any questions about your rights or benefits under the Workers222 Compensation Law. Keep a copy for your records. Missouri Division of Workers222 Compensation is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. TDD/TTY: 800-735-2966 Relay Missouri: 711 + American LegalNet, Inc. www.FormsWorkFlow.com