IC Form MSC5 (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 v. REPORT OF MEDIATOR , Defendant , Carrier Mediatortelephone fax Address The undersigned mediator reports the following results of a mediated settlement conference in this case: Conference was held and completed on:. was held but not completed because. was not held because: . Anticipated Date of Completion: Number of sessions held: Names of parties, attorneys, insurance representatives or others who were absent: The parties reached: agreement on all issues. an impasse. agreement on the following issues: If this case was not settled in mediation, and there is a pending request for hearing, the parties estimate that the length of the hearing in this case will be . Issues settled to be disposed of by: clincher other agmt. voluntary dismissal removal from hearing docket The person who will submit the agreement/clincher /dismissal to the Commission is , who will submit it by (date). Mediator's Fee ADMINISTRATIVE FEE: $ ($150.00 for appointed mediator) MEDIATION FEE: $ Total time spent in Mediated Settlement Conference: . hours ($150.00 per hour for appointed mediator, billed in quarter hour segments.) OTHER FEE (Postponement fee, etc...., if any) $ TOTAL FEE $ All fees to the mediator have been paid except as follows: Party owing fee Amount owed Address of party I have returned this report to the Commission within seven days of the conclusion of the mediated settlement conference. This the day of , . Mediator This report is to be returned to the Commission in all cases, whatever the mediation results. American LegalNet, Inc. www.FormsWorkFlow.com