North Carolina > Workers Comp
Mediated Settlement Agreement (Alternative Version) MSC9 - North Carolina
| Mediated Settlement Agreement (Alternative Version) Form. This is a North Carolina form and can be used in Workers Comp . |
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IC Form MSC9 (rev. 4/11) NORTH CAROLINA INDUSTRIAL COMMISSION I.C. FILE NUMBER: ________ _________________________, Plaintiff v. __________________________, Defendant-Employer __________________________, Defendant-Insurer At the mediation of this matter on _____________________________ in _________________________, North Carolina, a resolution of the issue in dispute in Plaintiff's above captioned Workers' Compensation claim was reached. The parties agree that: , , , , , ___________________________________________________________________________________________________, ___________________________________________________________________________________________________, ___________________________________________________________________________________________________, ___________________________________________________________________________________________________. MEDIATED SETTLEMENT AGREEMENT The _____________________ will be drafted by_______________________________ in accordance with N.C. Gen. Stat. Sections 97-17, 97-18, 97-82 and NCIC Rule 501. Entered into this the _______day of __________________, 20___. _________________ Plaintiff ___________________ Defendant ______________________ Mediator __________________ Plaintiff's Attorney State Bar No. _________ __________________ Defendant's Attorney State Bar No. _________ ______________________ Translator If this MSA is signed by a Translator Plaintiff certifies that the person whose name appears above translated/read this MSA to Plaintiff before Plaintiff signed the MSA. This MSA was translated to/read to Employee in the following language: ________________________. By signing above, Mediator attests that the participants at the MSC signed this MSA in the mediator's presence at the conclusion of the MSC. American LegalNet, Inc. www.FormsWorkFlow.com
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