Application For Informal/mediation Conference printable pdf download

Government of the District of Columbia

Department of Employment Services

Office of Workers’ Compensation

P.O. Box 56098

Washington, D.C. 20011

APPLICATION FOR INFORMAL /MEDIATION CONFERENCE

Name of party on whose behalf this application is submitted: _____________________________

Insurer Claim No.: ______________________________________________________________

OWC NO.: _____________________________________________________________________

Date of Injury: __________________________________________________________________

•

IF THE PARTY APPLYING FOR INFORMAL CONFERENCE IS

REPRESENTED AND THE REPRESENTATIVE HAS NOT ENTERED HIS/HER

APPEARANCE, A COPY OF THE REPRESENTATIVE’S AUTHORIZATION

MUST BE ATTACHED TO THIS APPLICATION.

Claimant’s name, address, and phone number :________________________________________

______________________________________________________________________________

Claimant’s representative’s name, address, and phone number: ___________________________

______________________________________________________________________________

Employer’s name, address, and phone number: ________________________________________

______________________________________________________________________________

Carrier’s name, address, and phone number: _________________________________________

______________________________________________________________________________

Employer/Carrier’s representative’s name, address, and phone number: ____________________

______________________________________________________________________________

•

THE PARTIES ARE ENCOURAGED TO MEET AND DISCUSS ANY AND ALL

ISSUES THAT THEY CAN AGREE UPON.

ISSUES TO BE DISCUSSED: ___________________________________________________

______________________________________________________________________________________

Employee’s Claims: _____________________________________________________________

______________________________________________________________________________

Employer/Carrier’s Position: ______________________________________________________

______________________________________________________________________________

_____________________________________________

Signature of Party Requesting Conference

LB2000

NOTE:

Informal procedures may include informal conferences and mediation conferences; provided, that

participation by interested parties in these conferences shall be voluntary.

Prior to the Informal Conference, all interested parties must submit all available information to

the Office at the earliest possible date. Informal conferences shall be held at the Office unless otherwise

designated. When requesting an informal conference outside the Office or by telephone, a statement

supporting good cause must be attached to Application. The Associate Director and/or Supervisor will

make the final decision.

Application For Informal/mediation Conference

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