Petition for Mediation Conference WORKER'S INFORMATION Worker's Email Worker's Name Phone Number Date of Accident WC Claim Number Part of Body Injured PETITIONER'S INFORMATION Petitioner's Name Address City Phone Number REPRESENTATIVE'S INFORMATION Representative's Name Address City Phone Number RESPONDENT'S INFORMATION Respondent's Name Address City Phone Number RESPONDENT'S REPRESENTATIVE'S INFORMATION Respondent's Representative's Name Address City Phone Number State Zip State Zip State Zip State Zip DLI-ERD-WCC072 REV 04/22/2014 American LegalNet, Inc. www.FormsWorkFlow.com DISPUTE INFORMATION What is your dispute with the Respondent? What attempt have you made to resolve your dispute with the Respondent? What was the Respondent's reply to your demand? Signature Date Please complete all fields. If you wish to save a copy of the form or print a copy, please do so. After you have done that, click Submit Request below. A dialog box will open asking which email application you would like to use. You can check the box Remember my Choice and you won't be prompted again. The form will then be emailed to the Employment Relations Division and you will receive a copy of the PDF in an email. Once the form is processed you will receive a notice via US Mail with the date and the time of the conference. Thank you. Your Name Your Email Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com