Internal Use Only: SUPREME COURT OF APPEALS OF WEST VIRGINIA Workers' Compensation Mediation Program Mediation Conference Request Re: Case Name: ___________________________________ Claim No.: ___________________________________ Appeal Board Order Date: _____________________ Supreme Court No.: ___________________________. Because the parties in the above-referenced case agree that a settlement conference could be helpful, the parties request the above-referenced case be included in the Court's Workers' Compensation Mediation Program. Select One. [ ] The parties will be making private mediation arrangements and will notify the Court of these arrangements within thirty (30) days of the filing of this request with the Court. [ ] The parties request that the Court schedule a mediation conference. If this option is selected, additional information on the program will be provided. Such information is available on the Court's WEB site (http://www.state.wv.us/wvsca). ___________________ Counsel for Claimant ___________________ Street Address ___________________ City, State, Zip ___________________ Telephone Number ___________________ Fax Number _____________________ Counsel for the Employer _____________________ Street Address _____________________ City, State, Zip _____________________ Telephone Number _____________________ Fax Number ____________________ Counsel for Division ____________________ Street Address ____________________ City, State, Zip ____________________ Telephone Number ____________________ Fax Number Return to: Office of Counsel Attn: Mediation Program Building 1, Room E-317 1900 Kanawha Blvd. E. Charleston, WV 25305-0831 Fax No. 558-6045 Mediation Form 1, Mediation Conference Request [7/24/98] American LegalNet, Inc. www.USCourtForms.com