Dispute Resolution System
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The document packet
provided to all employers and employees who are part of the ADR program
can be downloaded below. All documents are PDFs and require
Acrobat Reader to view.
- ENTIRE PACKET (338k) Includes all pages and forms below.
- Acknowledgement Form
- Workers' Compensation Addendum
- Program Overview Documents
- Medical Provider Network
- Rules of Practice and Procedure
ADR Forms (All forms are now typeable)
- FULL SET -- Forms 100, 102-108, 110, 200-201, 300 (485k)
- Form 100 – Information Provided to Interested Persons
Where
information is requested from the Basic Crafts Workers’ Compensation
Program, it may be provided to the interested person by attaching it to
this form and sending it to the interested person.
- Form 102 – Notice of Ombudsman’s Final Response
Where
the employee is not represented by counsel and the Ombudsman cannot
resolve a dispute, a final response will be provided to the employee,
and the employee will have the right to file a Workers’ Compensation
Grievance within 30 days of the final response and seek an Informal
Conciliation before a mediator.
- Form 103 – Workers’ Compensation Grievance
This
document must be filed within 30 days of the issuance of the Notice of
Ombudsman’s Final Response, in the case of an unrepresented injured
worker, or within 30 days of the issuance of the carriers’ final
response, in the case of a represented injured worker. This time
limit may be extended by the ADR Director upon a showing of good
cause. The filing of a Grievance will result in the setting of an
informal conciliation with a mediator, forthwith.
- Form 104 - Workers’ Compensation Grievance – Death Case
This is essentially the same form as form 103, but applies to cases where the injury resulted in death.
- Form 105 – Director’s Notice of Informal Conciliation
Upon
the filing of a Workers’ Compensation Grievance, the ADR Director will
issue a panel of prospective mediators to the parties, requesting
agreement or selection by the striking of names. When a mediator
is selected, the ADR Director will schedule an informal conciliation
and issue this form as confirmation.
- Form 106 – Arbitration Request
Where
the Informal Conciliation does not result in an agreement either
party may file a Request to Arbitrate within 30 days of the Informal
Conciliation.
- Form 107 – Declaration of Readiness to Arbitrate
When
prepared to go forward, a Declaration of Readiness to Arbitrate shall
be filed with the Basic Crafts ADR Director, and the ADR Director shall
schedule the Arbitration proceeding as soon as possible, while allowing
the parties time to prepare.
- Form 108 – Notice to Testify and Produce
This
is the document used to subpoena both persons to testify and documents
to be produced in a proceeding conducted under the jurisdiction of the
Basic Crafts Workers’ Compensation Program.
- Form 110 – ADR Director’s Notice of Scheduled Arbitration
After
a Request to Arbitrate has been timely filed, and when a party is
prepared to go forward, a Declaration of Readiness to Arbitrate shall
be filed with the Basic Crafts ADR Director, and the ADR Director shall
schedule the Arbitration proceeding as soon as possible, while allowing
the parties time to prepare.
- Form 200 – Compromise and Release
This
is the document used to prepare a settlement agreement to resolve a
claim or claims, usually on a lump sum basis in a manner that closes
the claim entirely.
- Form 200(b) - Order Approving C&R
- Form 201 – Stipulations with Request for Award
This
is the document used to prepare a settlement agreement to resolve a
claim or claims on the basis of a series of stipulations regarding the
issues in dispute. This approach to resolution most closely
resembles the effect of an arbitrators Findings and Award.
- Form 300 – Lein Claim
NOTICE AND REQUEST FOR ALLOWANCE OF LIEN
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