Wcc Form 70 - South Carolina Workers' Compensation Commission

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South Carolina Workers’ Compensation Commission

WCC File #:

1333 Main Street, Suite 500

Carrier File #:

Post Office Box 1715

Columbia, South Carolina 29202-1715

Carrier Code #:

(803) 737.5675

Employer FEIN #:

Employer's Name: ________________________________________________

Claimant's Name: ___________________________

SSN: ______________

Address: ________________________________________________________

City: _____________________________

State:

Zip: ___________

City: ____________________________ State:

Zip: ______________

Home Phone:

Work Phone:

Insurance Carrier:

Claimant's Attorney: _______________________________________________

Employer Carrier Attorney: _________________________________________

Phone: _____________

Email: _____________________________________

Phone: _________________ Email: __________________________________

________________________________________

______________________________

____

__________________

Preparer’s Signature

Title

Date

Pursuant to Reg. 67-1803 A. and 67-1809, the undersigned duly qualified Mediator reports the following results of the mediation held

on____________ (m/d/yyyy):

The following issues mediated and are settled or contested as indicated below:

ISSUE

SETTLED

CONTESTED

Per agreement of the Parties the matter is to be:

Rescheduled pursuant to Reg. 67-1804 C. on ____________________.

Set for hearing to determine all issues.

Set for hearing to determine remaining issues pursuant to the Forms 58.

Returned to General Files pending request for hearing from either Party.

The

Claimant

Defendants shall submit the Final Agreement & Release, Consent Order, Form 16A, or other appropriate

documentation regarding the agreement to the Commission.

The costs of the mediation is : $____________.

The cost was shared equally by the Parties.

The total cost was paid by the

Claimant

Defense.

The cost was paid pursuant to an Order of the Commission pursuant to Reg. 67-1807.

Mediator: _________________________________________ Address: ___________________________________________________________________

Phone: ____________________ Email: ____________________________________________________________________________________________

This report is to be returned to the Commission in all cases, whatever the mediation results. This form is used solely for tracking purposes

and does not become a part of the Commission file.

Questions about the use of this form should be directed to the Judicial Department at 803-737-5675, or mediation@wcc.sc.gov. Refer to Regulation 67-1801.

WCC FORM # 70

MEDIATOR REPORT

Created 7/13