SD EForm - 1652 V1 MEDIATION REQUEST FORM Date: By completing this form and sending it to the Department, you are requesting a mediation. You will be contacted by phone to schedule the mediation within two to three weeks. Name: Address: Social Security No: Date of Injury: Daytime Phone No: (where you can be reached to schedule the mediation) Please list all of the issues you would like to discuss during the mediation. In addition, attach any documents you have to support your position, including any medical records. Please send this form to: South Dakota Department of Labor and Regulation Division of Labor and Management 700 Governors Dr. Pierre, SD 57501 Phone: (605) 773-3681 Fax: (605) 773-4211 American LegalNet, Inc. www.FormsWorkFlow.com