Report Of Mediator Form - North Carolina
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1I.C. Form MSC5 (Rev. 9/01)
NORTH CAROLINA INDUSTRIAL COMMISSION
N.C. Industrial Commission
Mediation Section
I.C. File No(s).
4342 Mail Service Center
Carrier No.
County
27699-4342
Raleigh, NC
, Plaintiff
REPORT OF MEDIATOR
v.
, Defendant
, Carrier
Mediator
Telephone (
)
-
Fax (
)
-
Address
-
Street Address/P.O. Box
City
State
ZIP Code
The undersigned mediator reports the following results of a mediated settlement conference in this case:
Conference
was held and completed on:
/ /
was held but not completed because:
was not held because:
Anticipated Date of Completion:
/ /
Number of sessions held:
If settled before conference, person who notified mediator:
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:
$
($125.00 for appointed mediator.)
.
MEDIATION FEE:
$
:
.
hours
Total time spent in Mediated Settlement Conference
($125.00 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
,
.
___________________________________
Mediator
This report is to be returned to the Commission in all cases, whatever the mediation results.
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