IC Form MSC1

________________________________	CONSENT ORDER
Plaintiff	FOR MEDIATED
v.	SETTLEMENT CONFERENCE
________________________________
Defendant
________________________________
Carrier

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

Upon the CONSENT of the parties to this claim, evidenced by the signatures below, the Commission ORDERS that the parties and their attorneys attend a mediated settlement conference, pursuant to ICMSC Rule 4(a).(The following may be stipulated by the parties. All matters not stipulated will be specified by the Commission or the mediator.)

The conference will be completed by ________________, 199__. The mediated settlement conference is to be held
at _____ o'clock, am/pm, on _________________, 199__. The location will be ________________________________. In cases where a Request for Hearing has been filed, the parties agree, subject to change upon motion, that:
____ this case not be set for hearing until mediation is completed.
____ this case not be set for hearing until after ____________________________________(date).
____ this case be set for hearing on the next available calendar, if possible.
____ this case be removed from the hearing docket until a subsequent Form 33 is filed.
In the event that the parties fail to agree on one of the four preceeding options, this case will be set for hearing on the next available calendar.

\

The mediator will be:	________________________________.
Address of mediator:	________________________________
	________________________________
	________________________________
Telephone and Fax numbers of mediator:	________________________________

The parties and the mediator have agreed upon the mediator's rate of compensation as follows (specify all terms of the compensation agreement): ____________________________________________________________________
________________________________________________________________________________________.

The parties have not been able to agree upon a mediator, but jointly request that the Commission appoint one. Unless indicated otherwise below, one will be chosen from the Commission's Mediator Appointee List [mediators who have complied with ICMSC Rule 8(b)]. Check one if applicable:
___ Any mediator who has successfully completed training certifiedby the Administrative Office of the Courts
___ A mediator certified by a Center belonging to the Mediation Network of North Carolina
___ A mediator who has successfully completed other formal mediation training
___ A mediator with a mediation firm (specify which firm):
       __________________________________________________
(A mediator appointed by the Commission will be compensated at the rate of $100 per hour for time spent in the mediated settlement conference, to be billed in quarter hour segments. In addition, a $100 preparation fee shall be paid unless a settlement agreement has been finalized and the conference canceled by the parties and the mediator is so notified more than seven days in advance of the date set for the conference.)

The persons attending the conference are listed on the attached page, which should include the IC file number and be entitled "Attachment to Form MSC1". (Please list each person's name and role in this case).

In addition to exchanging all medical and rehabilitation records available to the parties and related to the injury in question, the parties agree to exchange the following documents at least 15 days prior to mediation: __________________
___________________________________________________________________________________

Optional: The parties agree that if the claim is not settled by mediation, then it shall be submitted to the following method of dispute resolution: _____________________________________________________________________
___________________________________________________________________________________

The mediator's fee will be paid at the conclusion of the conference. Parties are obligated for shares of the mediator's fee as specified in ICMSC Rule 7(d), unless they agree otherwise. The Defendant(s) shall pay the Compensation Plaintiff's share, as well as its own, and shall be reimbursed the Plaintiff's share when the case is concluded, or may withhold said share from any lump sum thereafter payable to Plaintiff; or, if none, then by reducing the last payment(s) of permanent partial benefits due; or, if none, as hereafter ordered on the motion of Defendant(s).

____ _______________________________ ____ ____________________________________
Date                  Signature of Plaintiff or Plaintiff's Attorney                Date                    Signature of Defendant or Defendant's Attorney

HEREBY ENTERED AND ORDERED, this ___ day of ________, 199__.

NORTH CAROLINA INDUSTRIAL COMMISSION

By: _______________________________
Commissioner/Deputy Commissioner/Mediation Coordinator