Oklahoma Workers' Compensation Commission

27562757
Mediation Conference Report
Mediation Conference Report
* Indicates Required Field
*Claim for Compensation (i.e. CC-Form-3 or CC-Form-3B) on File With the Workers’ Compensation Commission? Yes No
*Commission File Number
*Claimant/InjuredWorker (FullName)
*Respondent/Employer (Name)
*Insurer (Name)
*Check One: Mediation By Mutual Agreement of the Parties (i.e. No Commission Order of Referral to Mediation) Commission Ordered Referral to Mediation
Mediation conference date: (Format: mm/dd/yyyy)
*Mediation conference location (City):
*Mediation conference location (County):
*Mediation conference length (hours and minutes)
*Results of the mediation conference. The was settled in full. The case was not settled. The case was settled in part; parties reached agreement on one or more issues or claims. The case was settled in part; case settled as to some parties, but not all parties.
Commments:
*Signature
*Date of Form Submittion (Format: mm/dd/yyyy)
If you would like to receive a confirmation email upon submission of this form, please enter your email here.
Submission of this form requires Internet Explorer 9.0 or higher (with Compatibility Mode off), Firefox, or Google Chrome.

Mediation Conference Report