Mediated Settlement Agreement (Alternative Version) {MSC9}

NORTH CAROLINA INDUSTRIAL COMMISSION IC Form MSC9 (rev. 06/2018) I.C. FILE NUMBER: , Plaintiff MEDIATED v. SETTLEMENT AGREEMENT , Defendant-Employer , Defendant-Insurer At the mediation of this matter on in , North Carolina, a resolution of the issue in dispute in Plaintiff222s above captioned Workers222 Compensation claim was reached. The parties agree that: , , , , , , , , . The will be drafted by in accordance with N.C. Gen. Stat. 247247 97-17, 97-18, 97-82 and 11 NCAC 23A .0501. Entered into this the day of , . Plaintiff Defendant Mediator Plaintiff222s Attorney Defendant222s Attorney Translator State Bar No. State Bar No. If this MSA is signed by a Translator Plaintiff certifies that the person whose name appears above translated/read this MSA to Plaintiff before Plaintiff signed the MSA. This MSA was translated to/read to Employee in the following language: . By signing above, Mediator attests that the participants at the MSC signed this MSA in the mediator222s presence at the conclusion of the MSC. American LegalNet, Inc. www.FormsWorkFlow.com