WORKERS' COMPENSATION COMMISSION MEDIATION REQUEST FORM *Top portion, including the Responding Party section, to be filled out by party requesting the mediation and returned to the Workers' Compensation Commission Counselor Division, 1915 N. Stiles Avenue Ste 231, Oklahoma City, OK 73105 *REQUESTING PARTY RESPONDING PARTY Name Address City State Zip Name Address City State Zip Phone Phone Other Phone Other Phone NATURE OF DISPUTE TO BE MEDIATED: Signature of Requesting Party Date Employer (At time of injury, if different from responding party) Address Phone Date of Injury NOTE: If a CC-Form-3 has been filed in this claim, the parties may schedule and proceed with mediation independent of the Commission's Counseling Division or file a CC-Form-13 to request referral by the Administrative Law Judge. *This portion to be filled out by the Responding Party RESPONDING PARTY: Signature of Responding Party Yes, I agree to mediate. / Name Printed No, I do not agree to mediate. / Phone / Date RETURN FORM TO: Workers' Compensation Commission Counselor Division 1915 North Stiles Avenue Ste 231 Oklahoma City, OK 73105 (405) 522-5308 or In-State Toll Free (855) 291-3612 Direct Questions to Workers' Compensation Commission Counselor Division E-Mail: Counselors@wcc.ok.gov For Commission Use Only Date of contact made with responding party: Agrees to Mediate: ______ Yes ______ No If yes, date consent to mediate was received: If no, date file closed Revised 2-2-16 American LegalNet, Inc. www.FormsWorkFlow.com