Mediated Settlement Agreement printable pdf download

I.C. Form MSC8

NORTH CAROLINA INDUSTRIAL COMMISSION

I.C. File No.

Plaintiff:

versus

MEDIATED SETTLEMENT AGREEMENT

Defendant(s):

Carrier(s)/Association:

At the Mediated Settlement Conference held on ______, the parties agree to the following as set forth herein. No

rights other than those arising under the provisions of the N.C. Workers’ Compensation Act are compromised or

released by this agreement. The parties and their counsel acknowledge all hand written notations on this agreement

were completed before signing except for those items initialed which indicate a change or addition after initial

signing.

1. Defendant(s) shall pay Plaintiff the total sum of $_________. The timing of said payment shall comply with

N.C.G.S. §97-18. ____ In consideration of this payment, Plaintiff knowingly and intentionally waives the right to

further benefits under the N.C. Workers’ Compensation Act for the injury which is the subject of this agreement.

Plaintiff and Defendant agree to execute all necessary Forms and/or a standard Compromise Settlement Agreement

which complies with N.C.G.S. §97-17. Such Forms and/or Agreement shall be prepared by Defendant and

submitted to the Commission within the time prescribed by the Commission.

2. Each of the parties hereto shall bear their own attorney’s fees and ____ pro rata share of the mediator’s fee (or)

___ Defendant(s) will pay the full mediation fee. Defendant will pay all costs incurred per I.C. Rule 502(2)d.

3. ___ All authorized medical expenses of Plaintiff related to the injury to the date of this agreement will be paid by

Defendant(s) per approval of the NCIC and the parties shall include all material medical, vocational and

rehabilitation reports known to exist of Plaintiff related to the injury to the date of this agreement as part of the

Compromise Settlement Agreement submitted to the Commission. (or) ____ The parties shall include a list of all

known medical expenses and the material medical, vocational and rehabilitation reports known to exist of Plaintiff

related to the injury to the date of this agreement as part of the Compromise Settlement Agreement submitted to the

Commission and ___ All medical expenses of Plaintiff related to the injury to the date of this agreement are

disputed and no medical expenses will be paid by Defendant(s). (or) ___ All medical expenses of Plaintiff related to

the injury to the date of this agreement will be paid by Defendant(s) per the approval of the NCIC, except the

following, which are disputed:

4. The parties hereto have considered their interests and the interests of any health plan that may have paid medical

expenses of Plaintiff and agree that their positions as to the payment of medical expenses are reasonable.

5. Plaintiff ___ has, (or) ___ has not, returned to work at the same or greater average weekly wage as was being

earned prior to the injury or occupational disease.

6. Defendant(s) ___ admitted this claim ___ (and) also reasonably denied Plaintiff’s claim for additional medical/

indemnity compensation (or) ___ reasonably denied Plaintiff’s claim for compensation and there is a need for

finality in this litigation.

Mediated Settlement Agreement