Fill and Sign the Petition for Workers Compensation Mediation Conference Montana Form

Petition for Workers’ Compensation Mediation Conference Notice : Under Montana law, parties must attempt to resolve their disputes BEFORE seeking mediation. Mediation is required in most cases before a petition may be fled in the Workers’ Compensation Court. If you have not attempted to resolve your diference with the respondent as required by law, the mediator may be asked to vacate or postpone the conference. To avoid this, make sure you have done the following before fling this petition: (1) Tell the respondent, in writing, what you want and why you think you are entitled to it. (2) Give the respondent 15 working days to respond to your request. You may fle for mediation sooner if your request is denied before 15 working days have passed. When mailing the mediation petition to us: (A) Attach copies of any information you will use during the mediation conference. This information can include medical reports, wage records, statements, etc. If the documents are not available when mailing this petition, you may send them to the mediator and respondent prior to the mediation conference. (B) If available, attach a copy of the First Report of Injury for your claim. If you have questions about these requirements or about flling out this form, you may call or write us at the telephone number or address listed below. EMPLOYMENT RELATIONS DIVISION WORKERS’ COMPENSATION MEDIATION 1805 PROSPECT AVE PO BOX 1728 HELENA MT 59624-1728 Telephone No: (406) 444-6534 FAX No: (406) 444-6854 Petition for Workers’ Compensation Mediation Conference 1. Worker’s Name Telephone Number Social Security Number Workers’ Compensation Claim Number Date of Accident Part of Body Injured (Party requesting mediation) 2. Petitioner’s Name Telephone Number Address 3. If you will not be representing yourself in the mediation process, give the following information about your representative:Name Telephone Number Address (Party with whom you have a dispute) 4. Respondent’s Name Telephone Number Address 5. What is your dispute with the respondent? 6. What attempt have you made to resolve your dispute with the respondent? 7. What was the respondent’s reply to your demand? All conferences are automatically scheduled by telephone unless the party requests an in-person conference. All in-person conferences are held in Helena . Check here if you wish to travel to Helena for an in-person conference. Signature Date Revised 7/1999 Date Stamp