Alternative Dispute Resolution Report

STATE OF VERMONT ­ Department of Labor Workers' Compensation Alternative Dispute Resolution Report Report due from mediator within 15 days of completion of mediation Claimant name Defendant name State File No.: Date of ADR Session Starting Time Finishing Time 1. Please indicate the names and addresses of all persons participating in the ADR Session. (If additional space is needed, please attach an additional sheet.) If any party is a corporation or other entity, please indicate the name and title of the representative. Identify with an asterisk the representative of each party who had decision-making authority. Participants Claimant Claimant's Counsel Defendant/Insurer Defendant/Insurer Counsel Employer representative Interested party Name Mailing Address City, State & Zip Code Interested party 2. Were all appropriate parties in attendance? Yes No If not, who failed to appear? List and summarize any substitute arrangement made regarding attendance at the ADR Session. 3. Partial Was full or partial settlement reached at the session? Full If so, please summarize and append any agreement of the parties. ______________________________________________ Mediator _____________________ Date American LegalNet, Inc. www.FormsWorkFlow.com