BEFORE THE IOWA WORKERS’ COMPENSATION COMMISSIONER
_______________________________________________________________
:
___________________________,
:
:
Claimant,
:
:
vs.
:
:
File No. ________________
____________________________, :
:
APPLICATION FOR
Employer,
:
:
MEDIATION
and
:
:
____________________________, :
:
Insurance Carrier,
:
Defendants.
:
_____________________________________________________________
[WITHIN BRACKETS CIRCLE APPLICABLE ALTERNATIVES]
1.
[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.
2.
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.
3.
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____.
4.
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