Fill and Sign the Carrier No DOC Templatepdffiller Form

IC Form MSC5 (rev. 10/2017) NORTH CAROLINA INDUSTRIAL COMMISSION F ILE VIA ELECTRONIC DOCUMENT FILING PORTAL I.C. File No. HTTP ://WWW .IC.NC .GOV /DOCFILING .HTML Carrier No. County NCIC-Mediation Section mediation@ic.nc.gov 1236 Mail Service Center Raleigh, NC 27699-1236 _______________________________, Plaintiff v. REPORT OF MEDIATOR ______________________ , Defendant __________________________________, Carrier Mediator________ ________________ telephone _________________________fax _______________________________ Address________________________________________________________________________________________________ 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: _____ 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, and there is a pending request for hearing, 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 ___________________________________ (date). Mediator's Fee ADMINISTRATIVE FEE: $____________ ($150.00 for appointed mediator) MEDIATION FEE: $____________ Total time spent in Mediated Settlement Conference : _______.___ hours ($150.00 per hour for appointed mediator, billed in quarter hour segments.) OTHER FEE (Postponement fee, etc...., if any) $_______________ TOTAL FEE $____________ All fees to the mediator have been paid except as follows: Party owing fee Amount owed Address of party ______________________________________________________________________________________________________ I have returned 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.