REQUEST 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 #__________________ SSN: _______________________ NAME: ________________________________________ Complaint Filed? _____ Yes _____ No
REQUEST/REFERRAL DATE: _______________________ REQUESTOR: ________________________________________________________________ PREFERRED LOCATION OF MEDIATION: ____ BOISE ____ IDAHO FALLS ____ COEUR D'ALENE ____ POCATELLO
____ TWIN FALLS ____ LEWISTON
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