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27492750
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):
Select County
Adair
Alfalfa
Atoka
Beaver
Beckham
Blaine
Bryan
Caddo
Canadian
Carter
Cherokee
Choctaw
Cimarron
Cleveland
Coal
Comanche
Cotton
Craig
Creek
Custer
Delaware
Dewey
Ellis
Garfield
Garvin
Grady
Grant
Greer
Harmon
Harper
Haskell
Hughes
Jackson
Jefferson
Johnston
Kay
Kingfisher
Kiowa
Latimer
Le Flore
Lincoln
Logan
Love
Major
Marshall
Mayes
Mcclain
Mccurtain
Mcintosh
Murray
Muskogee
Noble
Nowata
Okfuskee
Oklahoma
Okmulgee
Osage
Ottawa
Pawnee
Payne
Pittsburg
Pontotoc
Pottawatomie
Pushmataha
Roger Mills
Rogers
Seminole
Sequoyah
Stephens
Texas
Tillman
Tulsa
Wagoner
Washington
Washita
Woods
Woodward
*
Mediation conference length (hours and minutes)
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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)
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