Free formmsc7.PDF - North Carolina

IC Form MSC7 (Rev. 9/01)

NORTH CAROLINA INDUSTRIAL COMMISSION

N.C. Industrial Commission Mediation Section 4342 Mail Service Center Raleigh, NC 27699-4342
________________________________, Plaintiff

v.
________________________________, Defendant ________________________________ , Carrier

REPORT OF EVALUATOR

Evaluator________________________ telephone _________________________fax _______________________________
Address_________________________________________________________________________________________________

The undersigned evaluator reports the following results of a neutral evaluation conference in this case: Conference ___ was held. ___ was not held. If not held, the reasons were: _______________________________________ ___________________________.Number of sessions held: _____ Date conference was completed: ___________________ 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, 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).
Evaluator's Fee

PREPARATION FEE:
EVALUATION FEE: Total time spent in Neutral Evaluation Conference: _______.___ hours
OTHER FEE (Postponement fee, etc...., if any)

$____________ $____________

$_______________

TOTAL FEE All fees to the evaluator have been paid except as follows: Party owing fee Amount owed

$____________ Address of party

____________________________________________________________________________________________________ I have mailed this report to the Commission within seven days of the conclusion of the neutral evaluation conference. This the ___ day of ________________, ______. ____________________________________________________ Evaluator Federal Tax ID No.

This report is to be returned to the Commission in all cases, whatever the neutral evaluation results.