IC Form MSC1 (rev. 06/2018) THIS FORM IS TO BE USED UNDER THE RULES FOR MEDIATED SETTLEMENT CONFERENCES OF THE NORTH CAROLINA INDUSTRIAL COMMISSION Attn:DisputeResolutionCoordinatorI.C.FileNo.NCIndustrialCommissionEmp.CodeNo.MediationSectionCarrierCodeNo.1236MailServiceCenterCarrierFileNo.Raleigh,NC276991236 CONSENT ORDER Plaintiff FOR MEDIATED v. SETTLEMENT CONFERENCE Defendant Carrier Appearances Name of Plaintiff or Plaintiff's Attorney Telephone and Fax numbers of Plaintiff or Plaintiff's Attorney Address of Plaintiff or Plaintiff's Attorney Name of Defendant or Defendant's Attorney Telephone and Fax numbers of Defendant or Defendant's Attorney Address of Defendant or Defendant222s Attorney Upon the CONSENT of the parties to this claim, evidenced by the signatures below, the Commission ORDERS that the parties and their attorneys attend a mediated settlement conference, pursuant to Rule 11 NCAC 23G.0104(a). (The following may be stipulated by the parties. All matters not stipulated will be specified by the Commission or the mediator.) The conference will be completed by , . The mediated settlement conference is to be held at o'clock, am/pm, on , (within120daysofmediationorder). The location will be . The mediator will be . Address of mediator Telephone and Fax numbers of mediator American LegalNet, Inc. www.FormsWorkFlow.com The parties and the mediator have agreed upon the mediator's rate of compensation as follows (specify all terms of the compensation agreement): . The parties have not been able to agree upon a mediator, but jointly request that the Commission appoint one. . (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 Rule 11 NCAC 23G.0107.) The persons attending the conference are listed on the attached page, which should include the IC file number and be entitled 223Attachment to Form MSC1224. (Please list each person222s name and role in this case). In addition to exchanging all medical and rehabilitation records available to the parties and related to the injury in question, the parties agree to exchange the following documents at least 15 days prior to mediation: Date Signature of Plaintiff or Plaintiff's Attorney Date Signature of Defendant or Defendant's Attorney HEREBY ENTERED AND ORDERED, this day of , . NORTH CAROLINA INDUSTRIAL COMMISSION By: Commissioner/Deputy Commissioner/Dispute Resolution Coordinator American LegalNet, Inc. www.FormsWorkFlow.com