IC Form MSC3 (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 ORDER FOR Plaintiff MEDIATED SETTLEMENT v. 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 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 143-296 and the Rules for Mediated Settlement Conferences of the North Carolina Industrial Commission (ICMSC Rules). Theconferenceshallbecompletedby,(within120daysofmediationorder). 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 American LegalNet, Inc. www.FormsWorkFlow.com of the parties222 failure to agree on a mediator on IC Form MSC 4. See Rule 11 NCAC 23G.0102. 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 Rule 11 NCAC 23G.0107. All parties, their attorneys and individuals with authority to settle the claim shall attend, as set forth in Rule 11 NCAC 23G.0104(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 American LegalNet, Inc. www.FormsWorkFlow.com