Free Mediation Request Form - Idaho

REQUEST FOR MEDIATION IDAHO WORKERS' COMPENSATION

Attention:

Dennis Burks, Industrial Commission PO Box 83720, Boise, ID 83720-0041 Phone: (208) 334-6000 Fax #: (208) 334-5145

Please complete form in detail: I.C. Claim #__________________ SSN: _______________________ NAME: ________________________________________ Complaint Filed? _____ Yes _____ No

REQUEST/REFERRAL DATE: _______________________ REQUESTOR: ________________________________________________________________ PREFERRED LOCATION OF MEDIATION: ____ BOISE ____ IDAHO FALLS ____ COEUR D'ALENE ____ POCATELLO

____ TWIN FALLS ____ LEWISTON

ISSUES TO MEDIATE: _________________________________________________________ This box to be completed by mediator: Mediation #: Date and Time Mediation Scheduled:

PARTIES AND ADDRESSES CLAIMANT: (If Pro-Se) CLAIMANT ATTORNEY:

EMPLOYER:

DEFENDANT ATTORNEY

SURETY:

FORMS\REQMEDIA