IC Form MSC5 (rev. 02/2016) NORTH CAROLINA INDUSTRIAL COMMISSION I.C. File No. Carrier No. FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML NCIC-Mediation Section email@example.com 4342 Mail Service Center Raleigh, NC 27699-4342 _______________________________, Plaintiff County v. REPORT OF MEDIATOR ______________________, Defendant __________________________________, Carrier Mediator________________________telephone _________________________fax _______________________________ Address________________________________________________________________________________________________ The undersigned mediator reports the following results of a mediated settlement conference in this case: Conference ___ was held and completed on:______________________________________________________________. ____was held but not completed because_________________________________________________________________. ___ was not held because: _____________________________________________________________________________. Anticipated Date of Completion:________ Number of sessions held: _____ 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). ADMINISTRATIVE FEE: ($150.00 for appointed mediator) Mediator's Fee $____________ $____________ MEDIATION FEE: Total time spent in Mediated Settlement Conference: _______.___ hours ($150.00 per hour for appointed mediator, billed in quarter hour segments.) OTHER FEE (Postponement fee, etc...., if any) $_______________ TOTAL FEE All fees to the mediator have been paid except as follows: Party owing fee Amount owed $____________ Address of party ______________________________________________________________________________________________________ I have returned this report to the Commission within seven days of the conclusion of the mediated settlement conference. This the ___ day of ________________, _________. ___________________________________ Mediator American LegalNet, Inc. www.FormsWorkFlow.com This report is to be returned to the Commission in all cases, whatever the mediation results. American LegalNet, Inc. www.FormsWorkFlow.com
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