OKLAHOMA WORKERS' COMPENSATION COMMISSION MEDIATION SYSTEM Date: Workers222 Compensation Commission File Number, (if any) INITIATING PARTY: RESPONDING PARTY: MEDIATION AGREEMENT We, the disputing parties, certify that this agreement shall constitute a mutually acceptable solution and shall abide by the following terms and conditions. WE AGREE THAT OUR OBLIGATIONS ARE AS FOLLOWS: WE FURTHER AGREE that in the event any disputes arise as to the terms of the agreement reached, the mediator shall be the sole, final arbiter of those disputes. We have read and understand this Agreement and agree to abide by its terms and conditions. INITIATING PARTY: RESPONDING PARTY: Initiating Party222s Attorney, If Any: Responding Party222s Attorney, If Any: Date: Date: Mediator American LegalNet, Inc. www.FormsWorkFlow.com