North Carolina > Workers Comp
Report Of Evaluator MSC7 - North Carolina
| Report Of Evaluator Form. This is a North Carolina form and can be used in Workers Comp . |
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IC Form MSC7 (rev. 4/11) NORTH CAROLINA INDUSTRIAL COMMISSION N.C. Industrial Commission Mediation Section 4342 Mail Service Center Raleigh, NC 27699-4342 _______________________________, Plaintiff v. REPORT OF EVALUATOR ______________________, Defendant __________________________________, Carrier Evaluator________________________telephone _________________________fax _______________________________ Address________________________________________________________________________________________________ The undersigned evaluator reports the following results of a neutral evaluation conference in this case: 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 in mediation, and there is a pending request for hearing, 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 ADMINISTRATIVE FEE: EVALUATION FEE: Total time spent in Neutral Evaluation Conference: _______.___ hours $____________ $____________ OTHER FEE (Postponement fee, etc...., if any) TOTAL FEE: All fees to the evaluator 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 This report is to be returned to the Commission in all cases, whatever the neutral evaluation results. American LegalNet, Inc. www.FormsWorkFlow.com
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