IC Form MSC4 (rev. 10/2017) NORTH CAROLINA INDUSTRIAL COMMISSION FILE VIA ELECTRONIC DOCUMENT FILING PORTAL I.C. File No. HTTP://WWW.IC.NC.GOV/DOCFILING.HTML Carrier No. County NCIC-Mediation Section mediation@ic.nc.gov 1236 Mail Service Center Raleigh, NC 27699-1236 Plaintiff DESIGNATION OF v. MEDIATOR Defendant Carrier Appearances Plaintiff222sAttorneyTelephone AddressFax Defendant222s AttorneyTelephone AddressFax THIS FORM IS TO BE COMPLETED BY EITHER THE PLAINTIFF OR THE DEFENDANT WITHIN THE TIME SPECIFIED IN THE COMMISSION222S ORDERS AND THE ICMSC RULES. Pursuant to the Order entered in the above captioned case, referring it to a mediated settlement conference, the parties have selected the DRCcertified mediator named below, who has agreed to serve. Mediator's name Telephone Address Fax Themediationconferenceisscheduledtoconveneonthefollowingdate:(within120daysofmediationorder). This the day of , . Signature of Plaintiff / Defendant or Representative American LegalNet, Inc. www.FormsWorkFlow.com