Report Of Evaluator Form - North Carolina
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1NORTH CAROLINA INDUSTRIAL COMMISSION
IC Form MSC7 (Rev. 9/01)
N.C. Industrial Commission
Mediation Section
4342 Mail Service Center
Raleigh, NC 27699-4342
________________________________,
Plaintiff
REPORT OF EVALUATOR
v.
________________________________,
Defendant
________________________________
, Carrier
Evaluator________
________________
telephone _________________________fax _______________________________
Address_________________________________________________________________________________________________
The undersigned e
reports the following results of a neutral evaluation conference in this case:
valuator
Conference ___ was held. ___ was not held. If not held, the reasons were: _______________________________________
___________________________.Number of sessions held: _____ Date conference was completed: ___________________
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, 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).
Evaluator’s
Fee
PREPARATION FEE:
$____________
EVALUATION
FEE:
$____________
eutral Evaluation
: _______.___ hours
Total time spent in N
Conference
OTHER FEE (Postponement fee, etc...., if any)
$_______________
TOTAL FEE
$____________
valuator
All fees to the e
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 neutral evaluation conference.
This the ___ day of ________________, ______.
____________________________________________________
Evaluator
Federal Tax ID No.
This report is to be returned to the Commission in all cases, whatever the neutral evaluation
results.
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