Mediators Declaration Of Interest And Qualification printable pdf download

Mediators Declaration Of Interest And Qualification

IC Form MSC6

NORTH CAROLINA INDUSTRIAL COMMISSION

N.C. Industrial Commission

Mediation Section

4342 Mail Service Center

Raleigh, NC 27699-4342

MEDIATOR'S DECLARATION

OF INTEREST AND

Mediator

QUALIFICATIONS

_______________________________

Address

_______________________________

__________________________

Telephone

_______________________________

__________________________

Fax

Please complete Section 1 or Section 2.

Section 1

I am qualified pursuant to ICMSC Rule 8(b) and desire appointment by the

Commission in WORKERS’ COMPENSATION CASES / STATE TORT CLAIMS

CASES / BOTH (indicate one). I certify my qualification by initialing each of the

following, as applicable:

_____ I am a mediator certified by the North Carolina Dispute Resolution Commission

to conduct Mediated Settlement Conferences in Superior Court cases.

_____ If an attorney, I am in good standing with the North Carolina State Bar.

_____ I agree to accept and perform mediations of disputes before the Industrial

Commission with reasonable frequency when called upon, for the fees and at rates of

payment specified by the Industrial Commission.

_____ I have completed the following North Carolina State Bar approved continuing

legal education course(s) on workers’ compensation law within the last two years:

Date

Course title and CLE credit given

Provider

______________________________________________________________________________________

Note: To remain eligible for appointment, a mediator is required to obtain six hours of CLE on

Workers’ Compensation every two years.

Mediators Declaration Of Interest And Qualification