Fill and Sign the Dispute Resolution Conf Report Form

BEFORE THE IOWA WORKERS’ COMPENSATION COMMISSIONER ____________________________________________________________________ : : : Claimant, : : File No. ____________ vs. : : : : DISPUTE RESOLUTION Employer, : CONFERENCE REPORT : and : : : : Insurance Carrier, : Defendants. : ____________________________________________________________________ The parties, in compliance with the Order setting this matter for conference, report to the deputy that: 1. Claimant (is) (is not) currently receiving weekly benefits. If not, state whether claimant has received any benefits since the date of injury, when those benefits ceased and why; or why benefits have not been initiated, if applicable. 2. The principal dispute(s) in this matter is (are): 3. The parties' contention for each disputed issue identified in paragraph 2, above, including a brief summary of the testimony expected to be presented to support the contentions, is attached hereto. 4. The parties can, for the purposes of this conference only, agree that: 5. The parties wish to bring the following information to the deputy's attention: 6. The parties certify that they have made a good faith attempt to settle the disputed issues. See, rule 876 IAC 10.1. If no attempts have been made, the deputy may cancel the mediation. Submitted by, ____________________________ __________________________________ Claimant Attorney for Claimant ___________________________ _________________________________ Representative of Attorney for Defendant Employer/Insurance Carrier 14-0041 09/98