North Carolina > Workers Comp
Consent Order For Mediated Settlement Conference MSC1 - North Carolina
| Consent Order For Mediated Settlement Conference Form. This is a North Carolina form and can be used in Workers Comp . |
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IC Form MSC1 (rev. 4/11) THIS FORM IS TO BE USED UNDER THE RULES FOR MEDIATED SETTLEMENT CONFERENCES OF THE NORTH CAROLINA INDUSTRIAL COMMISSION Attn: Dispute Resolution Coordinator I. C. File No. _____________________ NC Industrial Commission Emp. Code No. ___________________ Mediation Section Carrier Code No. __________________ 4342 Mail Service Center Carrier File No. ___________________ Raleigh, NC 276994342 ________________________________ Plaintiff v. ________________________________ Defendant CONSENT ORDER FOR MEDIATED SETTLEMENT CONFERENCE ________________________________ Carrier Appearances ________________________________ Name of Plaintiff or Plaintiff's Attorney _________________________________________ Telephone and Fax numbers of Plaintiff or Plaintiff's Attorney ______________________________________________________________________________ Address of Plaintiff or Plaintiff's Attorney ________________________________ Name of Defendant or Defendant's Attorney __________________________________________ Telephone and Fax numbers of Defendant or Defendant's Attorney ______________________________________________________________________________ Address of Defendant or Defendant's Attorney Upon the CONSENT of the parties to this claim, evidenced by the signatures below, the Commission ORDERS that the parties and their attorneys attend a mediated settlement conference, pursuant to ICMSC Rule 4(a).(The following may be stipulated by the parties. All matters not stipulated will be specified by the Commission or the mediator.) The conference will be completed by ________________, _______. The mediated settlement conference is to be held at _____ o'clock, am/pm, on _________________, _______ (within 120 days of mediation order). The location will be __________________________________. The mediator will be _____________________________. Address of mediator __________________________________________________ __________________________________________________ __________________________________________________ Telephone and Fax numbers of mediator ______________________________________ American LegalNet, Inc. www.FormsWorkFlow.com The parties and the mediator have agreed upon the mediator's rate of compensation as follows (specify all terms of the compensation agreement): _________________________ _____________________________________________________________________________. The parties have not been able to agree upon a mediator, but jointly request that the Commission appoint one. ______. (A mediator appointed by the Commission will be compensated at the rate of $150 per hour for time spent in the mediated settlement conference, to be billed in quarter hour segments, in addition to a $150 administrative fee, in accordance with ICMSC Rule 7.) The persons attending the conference are listed on the attached page, which should include the IC file number and be entitled "Attachment to Form MSC1". (Please list each person's name and role in this case). In addition to exchanging all medical and rehabilitation records available to the parties and related to the injury in question, the parties agree to exchange the following documents at least 15 days prior to mediation: ___________________________________________________________ ___________________________________________________________________________________ ____ _______________________________ ____ ____________________________________ Date Signature of Plaintiff or Plaintiff's Attorney Date Signature of Defendant or Defendant's Attorney HEREBY ENTERED AND ORDERED, this ___ day of ________, ________. NORTH CAROLINA INDUSTRIAL COMMISSION By: _______________________________ Commissioner/Deputy Commissioner/Dispute Resolution Coordinator American LegalNet, Inc. www.FormsWorkFlow.com
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