Ic Form Msc3 – Fill Out and Use This PDF

IC Form MSC3 (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 27699‐4342
_______________________________	ORDER FOR
Plaintiff	MEDIATED SETTLEMENT
v.	CONFERENCE

_______________________________

Defendant

_______________________________

Carrier

	Appearances
________________________________	_________________________________________
Name of Plaintiff or Plaintiff's Attorney	Telephone number of Plaintiff or Plaintiff's Attorney

______________________________________________________________________________

Address of Plaintiff or Plaintiff's Attorney

________________________________	__________________________________________
Name of Defendant or Defendant's Attorney	Telephone number of Defendant or Defendant's Attorney

______________________________________________________________________________

Address of Defendant or Defendant’s Attorney

IT IS ORDERED that the parties in the above captioned case and their attorneys participate in a mediated settlement conference pursuant to NC General Statutes 97- 80(c) and the Rules for Mediated Settlement Conferences of the North Carolina Industrial Commission (ICMSC Rules).

The conference shall be completed by ________________, _______ (within 120 days of

mediation order).

The parties have 21 days from the date of this Order to select by agreement a mediator or to designate by agreement the Commission's list from which the parties desire that the Commission select a mediator. Within 21 days of the date of this Order, the

Defendant or the Defendant's counsel shall file a stipulation as to the mediator or notice of the parties’ failure to agree on a mediator on IC Form MSC 4. See ICMSC Rule 2.

The parties and a mediator selected by agreement shall agree upon the mediator's rate of compensation. 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.

All parties, their attorneys and individuals with authority to settle the claim shall attend, as set forth in ICMSC Rule 4(a).

The parties shall exchange all medical and rehabilitation records available to the parties related to the injury in question and any recorded statements, expert opinions, reports and other documents, tapes and photographs that are relevant or material to the issues in controversy at least 15 days prior to mediation.

This case will be set for hearing on the next available calendar to be heard in due course unless sooner settled by mediation.

HEREBY ENTERED AND ORDERED, this ___ day of ________, _______.

NORTH CAROLINA INDUSTRIAL COMMISSION

By: __________________________________

Commissioner/Deputy Commissioner/Dispute Resolution Coordinator