Free Form MSC5 - North Carolina

I.C. Form MSC5 (Rev. 9/01)

NORTH CAROLINA INDUSTRIAL COMMISSION

N.C. Industrial Commission
Mediation Section

4342 Mail Service Center Raleigh, NC 27699-4342
, Plaintiff v. , Defendant , Carrier Mediator Address
Street Address/P.O. Box City

I.C. File No(s). Carrier No. County

REPORT OF MEDIATOR

Telephone (
State

)

-

Fax (

)

ZIP Code

The undersigned mediator reports the following results of a mediated settlement conference in this case: Conference was held and completed on: / / was held but not completed because: was not held because: Anticipated Date of Completion: / / Number of sessions held:

If settled before conference, person who notified mediator: Names of parties, attorneys, insurance representatives or others who were absent: The parties reached: agreement on all issues. an impasse. agreement on the following issues:

If this case was not settled in mediation, the parties estimate that the length of the hearing in this case will be Issues settled to be disposed of by: clincher. other agmt. voluntary dismissal. removal from hearing docket

The person who will submit the agreement/clincher /dismissal to the Commission is , who will submit it by Mediator's Fee PREPARATION FEE:
($125.00 for appointed mediator.)

(date). . .

$ $ . hours $ $

MEDIATION FEE:
Total time spent in Mediated Settlement Conference:
($125.00 per hour for appointed mediator, billed in quarter hour segments.)

OTHER FEE (Postponement fee, etc...., if any) TOTAL FEE Mediator's Federal Tax ID No. All fees to the mediator have been paid except as follows: Party owing fee Amount owed Address of party

. .

I have mailed this report to the Commission within seven days of the conclusion of the mediated settlement conference. This the day of ___________________________________ Mediator This report is to be returned to the Commission in all cases, whatever the mediation results. , 200 .