Form 14-0137 - Application For Mediation Page 2
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1
2assigned deputy workers’ compensation commissioner
fully prepared to enter into meaningful discussions
relative to resolving this claim.
5.
The applicant(s) further understand(s) that the
assigned deputy must consent before the claimant or a
claim representative is excused from appearing
personally.
Such consent must be sought on written
motion prior to commencement of mediation.
When the
claimant or a claim representative fails to personally
appear for mediation without the consent of the
assigned deputy, the mediation shall be cancelled.
Additional sanctions may be imposed at the discretion
of the deputy.
Signed this ________ day of ___________________, _____.
_____________________________
_______________________
ATTORNEY FOR CLAIMANT
ATTORNEY FOR DEFENDANT(S)
_____________________________
_______________________
ATTORNEY FOR_________________
ATTORNEY FOR __________
14-0137
1/2000
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