Fill and Sign the This Form is to Be Used under the Rules North Carolina

I.C. Form MSC2 (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 v. __________________________________ Defendant __________________________________ Carrier PETITION FOR ORDER REFERRING CASE TO MEDIATED SETTLEMENT CONFERENCE Appearances Name of Plaintiff or Plaintiff’s Attorney Telephone and Fax numbers of Plaintiff or Plaintiff’s Attorney Address of Plaintiff or Plaintiff’s Attorney Name of Defendant or Defendant’s Attorney Telephone and Fax numbers of Defendant or Defendant’s Attorney Address of Defendant or Defendant’s Attorney Now comes the undersigned party, petitioning the Commission to order the above captioned case to a mediated settlement conference pursuant to the Rules for Mediated Settlement Conferences of the Industrial Commission, and in support of the Petition says: This case should be ordered to a mediated settlement conference for the following reasons (attach additional pages if necessary, designated with the I.C. file number and titled “Attachment to Form MSC2”): Notice to parties: Objections must be filed in writing with the Commission within 10 days of the service of this petition and may be ruled on by the Commission without further hearing. The foregoing motion was served by Petitioner on all non-moving parties by depositing a copy of same with the U.S. Postal Service, in a postage-paid envelope, addressed to the last known address of all non-moving parties or of said parties’ attorney(s), as listed below: This the _____ day of ________________, ____. Petitioner: