Fill and Sign the Request for Voluntary Mediation for Workers Compensation Colorado Form

Claimant Name:      Daytime Phone #-       WC#:       Date of Injury:       Social Security #-       Name of Attorney (if represented):       Attorney Phone #-       Insurance Carrier:       Carrier File #-       Adjuster Name:       Phone #-       Name of Attorney (if represented):       Attorney Phone #-       Employer:       Employer FEIN #-       Contact Person:       Phone #-       Name of Attorney (if represented):       Attorney Phone #-       Name:       Daytime Phone #-       Requestor's Signature:       Date of Request:             DIVISION OF WORKER'S COMPENSATION, MEDIATION SECTION1515 ARAPAHOE, TOWER 2, SUITE 620, DENVER, CO 80202-2117 PHONE: 303.318.8730 FAX: 303.318.8698 REQUEST FOR VOLUNTARY MEDIATION SERVICES This form is not required. Mediation services may be requested by any party by using this form or by calling the above phone number. Please complete as much of the following information as possible: If there are more carriers, employers or attorneys involved, please list their names and phone numbers on the back of the form. The following party to this claim requests mediation services: If more than one party is requesting mediation services, please provide the name, phone number, signature and date on the back of the form. Issues for Mediation: Please provide a brief description of the issues in dispute: (Use back of form if needed) The Colorado Worker's Compensation Act, Section B-43-205(l), allows any party to request mediation to resolve any issue. If all parties agree to participate, mediation will occur as soon as possible. Mail or fax this form to the address at the top of the form. You may also request mediation services by calling the Mediation Section at 303.318.8730. When this form or your phone call is received, a mediator will call all parties to encourage voluntary participation, discuss scheduling and gather information about the dispute. The mediation process begins with this telephone contact. All information discussed with the mediator will be held in strict confidence, pursuant to C.R.S. Section B-43-205(2). WC27 Rev 4/96.00