Application For Informal Mediation Conference

Government of the District of Columbia Department of Employment Services Office of Workers' Compensation 4058 Minnesota Avenue, N.E. Washington, D.C. 20019 APPLICATION FOR INFORMAL / MEDIATION CONFERENCE Name of party on whose behalf this application is submitted: _____________________________________________________________________ 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 name, address, and phone number: ________________________________________________________________________________ ______________________________________________________________________________________________________________________ Claimant representative's name, address, and phone number: ____________________________________________________________________ ______________________________________________________________________________________________________________________ Employer name, address, and phone number: ________________________________________________________________________________ _______________________________________________________________________________________________________________________ Carrier name, address, and phone number: ___________________________________________________________________________________ _______________________________________________________________________________________________________________________ Employer/Carrier representative's name, address, and phone number: ___________________________________________________________ _______________________________________________________________________________________________________________________ ISSUES TO BE DISCUSSED: ___________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Employer/Carrier Position: ______________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _________________________________________________ Signature of Party Requesting Conference Informal procedures may include informal conferences and mediation conferences provided that participation by interested parties in these conferences is voluntary. Informal conferences shall be held at the Office or by telephone. A statement supporting good cause must be attached to the Application. The Associate Director and/or Supervisor will make the final decision. One major purpose of the informal conference is to amicably dispose of controversies, whenever possible. It is a requirement that: all pertinent written / documentation (i.e.) (factual, medical, etc.) shall be provided to the office and exchanged among all parties at the earliest possible date, or at least 48 hours prior to the commencement of the conference. [This process serves to assist in ensuring an expeditious resolution of controversies.] American LegalNet, Inc. www.FormsWorkFlow.com