GSIAs

 This form may be used by legal counsel to request Full and Final Mediation by a Commission mediator as a means of reaching a compromise settlement. Filing instructions are included on the form. Once the form is received, ADR Department staff will contact all other parties to confirm whether they are also interested in mediating the dispute.

 This form may be used by injured workers, deceased worker claimants, medical provider claimants, employers, insurers, claim administrators, and legal counsel to request Issue Mediation by a Commission mediator as a means of resolving a claims dispute. Filing instructions are included on the form. Once the form is received, ADR Department staff will contact all other parties to confirm whether they are also interested in mediating the dispute.

 This form describes the mediation process and related Code of Virginia provisions. When one or more parties to a mediation does not have legal counsel to represent them at the mediation, Mediation Consent Form B is used, which requires a neutral facilitation style by the mediator (see paragraph 7).

 This form describes the mediation process and related Code of Virginia provisions. When all parties to a mediation have legal counsel to represent them at the mediation, Mediation Consent Form A is used, which allows the parties to choose a neutral evaluation style and/or a neutral facilitation style by the mediator (see paragraph 7).

 This form may be used by employers, insurers, or claims administrators to notify the ADR Department whether a Medical Provider Application

• is or will be accepted and paid;
• is under review for repricing, negotiation, or other reason; or
• is denied and for what reason; and
• whether the employer, insurer, or claims administrator consents to issue mediation with the medical provider to try and resolve the claim together, with the help of a mediator, without the need for a hearing.

 This form may be used by employers, insurers, or claims administrators to notify the ADR Department whether an injured worker’s Change in Condition Claim.

• is accepted, accepted in part and denied in part, or denied;
• the reasons for acceptance or denial, and, if denied in whole or in part;
• whether the employer, insurer, or claims administrator consents to issue mediation with the injured worker to try and resolve the claim together, with the help of a mediator, without the need for a hearing.

Mediation participants may use this form to provide feedback to the ADR Program Manager on mediator performance, mediation case management, and suggestions for enhancing program services. The information provided will not be used in any personnel matter.

Pursuant to Code of Virginia §§ 65.2-800 and 58.1-3714 signed certifications of insurance coverage are to be provided by the contractor to the localities.

This form is used to report a work place injury to the Commission or to the Insurance Carrier/Claim Administrator depending on the date of injury. For all injuries occurring on or after October 1, 2008, this form should only be used to notify the insurance carrier/claim administrator of a work place injury. For injuries that occurred before October 1, 2008, that have not been reported to the Commission, the employer should use this form to report the injury so that Jurisdiction Claim Number can be assigned.