Form 14-0137 - Application For Mediation printable pdf download

Form 14-0137 - Application For Mediation

BEFORE THE IOWA WORKERS’ COMPENSATION COMMISSIONER

_______________________________________________________________

___________________________,

Claimant,

vs.

File No. ________________

____________________________, :

APPLICATION FOR

Employer,

MEDIATION

and

____________________________, :

Insurance Carrier,

Defendants.

_____________________________________________________________

[WITHIN BRACKETS CIRCLE APPLICABLE ALTERNATIVES]

[Claimant/Defendant(s)/All Parties] request(s) that

prior to scheduling for hearing the above matter(s) be

scheduled for mediation as provided in rule 876 IAC

4.40.

Pursuant to rule 876 IAC 4.40(3) and rule 876 IAC 10.1,

the applicant(s) professionally state(s) [its/their]

good faith effort to resolve the dispute(s) prior to

filing of this application.

The applicant(s) has/have consulted with all other

parties involved with this workers’ compensation claim:

(1) Those parties [consent to/resist] the application

for mediation; (2) All parties agree that should the

division order the parties to appear for mediation, the

mediation may be scheduled on or after

__________________, 20____.

The applicant(s) understand(s) that should the division

order mediation, the claimant and a claim

representative of the employer or its insurance carrier

duly authorized to settle the disputed issue(s)shall

personally appear with their legal counsel before the

Form 14-0137 - Application For Mediation