ADDENDUM A—I.C. Form MSC5
IC Form MSC5
NORTH CAROLINA INDUSTRIAL COMMISSION| John C. Schafer Dispute Resolution Coordinator 430 North Salisbury Street Raleigh, NC 27611 |
I.C. File
No.________________ |
| _______________________________________,
Plaintiff v. _______________________________________, Defendant _______________________________________, Carrier |
REPORT OF MEDIATOR |
| Mediator________________________telephone
_________________________fax __________________________________ Address________________________________________________________________________________________________ The undersigned mediator reports the following results of a mediated settlement conference in this case: Conference ___ was held. ___ was not held. If not held, the reasons were:___________________________________________ ____________________________.Number of sessions held: _____ Date conference was completed:______________________ 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 ___________________________________ (date). |
Mediator’s Fee |
| PREPARATION FEE: ($100.00 for appointed mediator unless settled and cancelled more than seven days before the conference date.) |
$_______________________ |
| MEDIATION FEE: Total time spent in Mediated Settlement Conference: _______.___ hours ($100.00 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 ________________, 199__. __________________________________________________ This report is to be returned to the Commission in all cases, whatever the mediation results. |
Go to Rules for Mediated Settlement and Neutral Evaluation Conferences Page