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IC Form MSC4 (rev. 10/2017) NORTH CAROLINA INDUSTRIAL COMMISSION FILE 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 DESIGNATION OF v. MEDIATOR __________________________________ Defendant __________________________________ Carrier Appearances Plaintiff’sAttorney_________________________________Telephone___________________________ Address___________________________________________Fax________________________________ ___________________________________________ Defendant’s Attorney_______________________________Telephone__________________________ Address___________________________________________Fax________________________________ ___________________________________________ THIS FORM IS TO BE COMPLETED BY EITHER THE PLAINTIFF OR THE DEFENDANT WITHIN THE TIME SPECIFIED IN THE COMMISSION’S ORDERS AND THE ICMSC RULES. Pursuant to the Order entered in the above captioned case, referring it to a mediated settlement conference, the parties have selected the DRC certified mediator named below, who has agreed to serve. Mediator's name ________________________________ Telephone __________________ Address ________________________________________ Fax ___________________ _________________________________________________ The mediation conference is scheduled to convene on the following date:  ______________________ (within 120 days of mediation order).  This the ___ day of ________________, ________. __________________________ Signature of Plaintiff / Defendant or Representative