Request For Mediation
ADVERTISEMENT
1REQUEST 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 #__________________
NAME: ________________________________________
SSN: _______________________
Complaint Filed?
_____ Yes
_____ No
REQUEST/REFERRAL DATE: _______________________
REQUESTOR: ________________________________________________________________
PREFERRED LOCATION OF MEDIATION:
____ BOISE
____ IDAHO FALLS ____ COEUR D'ALENE
____ TWIN FALLS ____ LEWISTON
____ POCATELLO
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
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal