Internal Use Only: SUPREME COURT OF APPEALS OF WEST VIRGINIA Workers' Compensation Mediation Program Mediation Statement 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 Re: Case Name: ______________________________ Claim No.: _______________________________ Appeal Board Order Date: __________________ Supreme Court No.: _______________________ Statement Submitted on behalf of: _________________________________________________________ Statement Submitted by: Name: _________________________________________________________ Address: ________________________________________________________ _________________________________________________________ Telephone: ____________________________ Type of Issues (Check all that apply.) [ ] TTD (Temporary [ ] PPD (Permanent Partial Total Disability) Disability) [ ] Occupational Hearing Loss [ ] Occupational Disease [ ] PTD (Permanent Total Disability) [ ] Death or Widow Benefits [ ] Medical Benefits [ ] Occupational Pneumoconiosis [ ] Other ___________________ (Please specify) Relief sought: __________________________________________________________________ (1) Does this appeal involve a question of first impression? [ ] Yes [ ] No (2) Could this claim involve the Second Injury Reserve? [ ] Yes [ ] No (3) Will the determination of this appeal turn on the interpretation or application of a particular case or statute? Case Name/Statute:_______________________________________ [ ] Yes [ ] No Citation:________________________________________________ (4) Are any related petitions currently pending before the Supreme Court? [ ] Yes [ ] No (If yes, cite the case name and the manner in which it is related on a separate sheet.) (5) Settlement Status:___________________________________________________________________ (6) Summary of Party's Position(s): (One additional sheet may be attached.) This Is To Certify That this Workers' Compensation Mediation Statement Was Mailed to the Clerk of the Supreme Court of Appeals of West Virginia, a Copy Thereof Was Served Upon The Mediator, Each Party or Their Counsel of Record and/or the Workers' Compensation Division this ____ Day of _____________, 20__ ____________________________________________ Signature of Counsel [ NOTE: Only this form and one additional page is permitted. No attachments.] Mediation Form 3, Mediation Statement [11/6/98] American LegalNet, Inc. www.USCourtForms.com