Department of Labor and Industry

Petition for Mediation

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 filed in the Workers' Compensation Court.  If you have not attempted to resolve your difference 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 filing 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 file for mediation sooner if your request is denied before 15 working days have passed.

 

Petition for Mediation Conference

* is a required field
Your Email
Invalid Input
   
Workers' Name *
Invalid Input
Phone Number *
Invalid Input
example: 406-444-4444
WC Claim Number *
Invalid Input
Date of Accident *
Invalid Input
example: 05/06/2011
Part of Body Injured
Invalid Input
   
Petitioner's Name *
Invalid Input
Address *
Invalid Input
City *
Invalid Input
State *
Invalid Input
Zip *
Invalid Input
Phone Number *
Invalid Input
example: 406-444-4444
   
If you will not be representing yourself in the mediation process, give the following information about your representative:
Name
Invalid Input
Address
Invalid Input
City
Invalid Input
State
Invalid Input
Zip
Invalid Input
Phone Number
Invalid Input
example: 406-444-4444
   
Respondent's Information
Name *
Invalid Input
Address
Invalid Input
City
Invalid Input
State
Invalid Input
Zip
Invalid Input
Phone Number
Invalid Input
example: 406-444-4444
   
Respondent's Representative (if any)
Name
Invalid Input
Address
Invalid Input
City
Invalid Input
State
Invalid Input
Zip
Invalid Input
Phone Number
Invalid Input
example: 406-444-4444
   
What is your dispute with the respondent? *
Invalid Input
   
What attempt have you made to resolve your dispute with the respondent? *
Invalid Input
   
What was the respondent's reply to your demand?
Invalid Input
   
Digital Signature *
Invalid Input
Date *
Invalid Input
Form page 9 of 9
Invalid Input

 

Contact Information

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