Mediators Declaration Of Interest And Qualification (Page 3 of 4) in pdf

North Carolina Industrial Commission

4342 Mail Service Center

Michael F. Easley, Governor

Raleigh, NC 27699-4342

To:

New Mediator

From: John C. Schafer, Dispute Resolution Coordinator

Due to the high settlement rates and positive responses to the use of mediation in workers’ compensation

cases, the Commission has begun sending all cases to mediation upon the filing of a Form 33 Request for

Hearing. To assist the parties in selecting a mediator, we are developing a roster of mediators which

includes a summary of their background and experience. Please fill out the questionnaire below, and return

this form to the Industrial Commission. If you do not complete it, you will still be one of our listed

mediators, but you will not be included in the more descriptive roster. If you have any questions, please

contact me at the above telephone number. Please also note that the revised mediator report forms that you

will begin receiving ask for an estimate of the length of the hearing in those cases that are not settled in

mediation.

If your address or contact numbers are incorrect, please mark the changes on this form.

How many hours one way are you willing to drive to conduct mediations assigned to you by the

Commission? __________

When did you become an AOC/DRC certified mediator? ______________

Approximately how many court cases have you mediated? __________

Approximately how many workers’ compensation cases have you mediated? __________

Please state the approximate number of cases in which you have represented a party in a workers’

compensation claim __________.

In what percentage of these workers’ compensation cases have you represented:

Employees___________%

Employers or Insurance Carriers______%

Please provide me with your hourly mediation fee, per case administration fee, and your policies and

charges (if any) for cancellations, travel time and expenses in those cases where you are selected by

agreement of the parties to be the mediator in IC cases. In cases where you are appointed by the

Commission, the rules do not provide for any such charges, unless the mediator and the parties otherwise

agree after the appointment, except for the $100.00 administration fee in the event that the case is settled

less than seven(7) days before a scheduled mediation conference, or by Order of the Commission in cases

where mediation is dispensed with after the mediator has been appointed.

Hourly Mediation Fee____________

Administration Fee______________

Cancellation Fee________________

Travel Fee_____________________

Mediators Declaration Of Interest And Qualification Page 3