IC Form MSC6 (rev. 06/2018) NORTH CAROLINA INDUSTRIAL COMMISSION E-mail to: mediation@ic.nc.gov N.C. Industrial Commission Mediation Section 1236 Mail Service Center Raleigh, NC 27699-1236 MEDIATOR'S DECLARATION Mediator OF INTEREST AND QUALIFICATIONS Address Telephone Fax Please complete Section 1 or Section 2. Section 1 I am qualified pursuant to Rule 11 NCAC 23G.0108(b) and desire appointment in cases pending before the Commission. I certify my qualification by initialing each of the following, as applicable: I am a mediator certified by the North Carolina Dispute Resolution Commission to conduct Mediated Settlement Conferences in Superior Court cases. If an attorney, I am in good standing with the North Carolina State Bar. I agree to accept and perform mediations of disputes before the Industrial Commission with reasonable frequency when called upon, for the fees and at rates of payment specified by the Industrial Commission. I have completed the following North Carolina State Bar approved continuing legal education course(s) on workers222 compensation law within the last two years: Date Course title and CLE credit given Provider American LegalNet, Inc. www.FormsWorkFlow.com Section 2 Pursuant to Rule 11 NCAC 23G.0108(c), I, the above named mediator, request that the North Carolina Industrial Commission place my name on the list of mediators with similar qualifications which the Commission makes available to parties selecting mediators in cases pending before the Commission. My pertinent qualifications and experience are: I have successfully completed the following mediation training: Date of training Course title and hours of training Provider If the training was not certified by the Dispute Resolution Commission or sponsored by a Center belonging to the Mediation Network of North Carolina, please attach a copy of the training agenda and a list of the trainers. I will notify the Commission if and when any of the above declarations or qualifications listed above no longer obtain. This the day of ,. Signature of Mediator Please indicate how many hours (one-way) you are willing to drive to conduct mediation conferences in cases in which you are appointed as the mediator by the Commission : American LegalNet, Inc. www.FormsWorkFlow.com North Carolina Industrial Commission 1236 Mail Service Center Raleigh, NC 27699-1236 To: New Mediator From: John C. Schafer, Dispute Resolution Coordinator Due to the high settlement rates and positive responses to the use of mediation in workers222 compensation cases, the Commission has begun sending all cases to mediation upon the filing of a Form 33 Request for Hearing. To assist the parties in selecting a mediator, we are developing a roster of mediators which includes a summary of their background and experience. Please fill out the questionnaire below, and return this form to the Industrial Commission. If you do not complete it, you will still be one of our listed mediators, but you will not be included in the more descriptive roster. If you have any questions, please contact me at the above telephone number. Please also note that the revised mediator report forms that you will begin receiving ask for an estimate of the length of the hearing in those cases that are not settled in mediation. If your address or contact numbers are incorrect, please mark the changes on this form. How many hours one way are you willing to drive to conduct mediations assigned to you by the Commission? When did you become an AOC/DRC certified mediator? Approximately how many court cases have you mediated? Approximately how many workers222 compensation cases have you mediated? Please state the approximate number of cases in which you have represented a party in a workers222 compensation claim . In what percentage of these workers222 compensation cases have you represented: Employees% Employers or Insurance Carriers% Please provide me with your hourly mediation fee, per case administration fee, and your policies and charges (if any) for cancellations, travel time and expenses in those cases where you are selected by agreement of the parties to be the mediator in IC cases. Hourly Mediation Fee Administration Fee Cancellation Fee Travel Fee Describe below or on a separate sheet in no more than 50 words your past experience in handling workers222compensation cases (i.e. plaintiffs222 attorney, defense attorney, mediator, insurance adjuster, Industrial Commission staff, etc.) Thank you for your assistance. American LegalNet, Inc. www.FormsWorkFlow.com