Mediator Report {70}

South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 Post Office Box 1715 Columbia, South Carolina 29202-1715 (803) 737.5675 www.wcc.sc.gov Claimant's Name: ___________________________ SSN: ______________ WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: Employer's Name: ________________________________________________ Address: ________________________________________________________ City: ____________________________ State: Insurance Carrier: Employer Carrier Attorney: _________________________________________ Phone: _________________ Email: __________________________________ Zip: ______________ Address: ________________________________________________________ City: _____________________________ Home Phone: State: Work Phone: Zip: ___________ Claimant's Attorney: _______________________________________________ Phone: _____________ Email: _____________________________________ ________________________________________ Preparer's Signature ______________________________ Title ____ Email __________________ Date Pursuant to Reg. 67-1803 A. and 67-1809, the undersigned duly qualified Mediator reports the following results of the mediation held on____________ (m/d/yyyy): The following issues mediated and are settled or contested as indicated below: ISSUE SETTLED CONTESTED Per agreement of the Parties the matter is to be: Rescheduled pursuant to Reg. 67-1804 C. on ____________________. Set for hearing to determine all issues. Set for hearing to determine remaining issues pursuant to the Forms 58. Returned to General Files pending request for hearing from either Party. The Claimant Defendants shall submit the Final Agreement & Release, Consent Order, Form 16A, or other appropriate documentation regarding the agreement to the Commission. The costs of the mediation is : $____________. The cost was shared equally by the Parties. The total cost was paid by the Claimant Defense. The cost was paid pursuant to an Order of the Commission pursuant to Reg. 67-1807. Mediator: _________________________________________ Address: ___________________________________________________________________ Phone: ____________________ Email: ____________________________________________________________________________________________ This report is to be returned to the Commission in all cases, whatever the mediation results. This form is used solely for tracking purposes and does not become a part of the Commission file. Questions about the use of this form should be directed to the Judicial Department at 803-737-5675, or mediation@wcc.sc.gov. Refer to Regulation 67-1801. WCC FORM # 70 Created 7/13 70 MEDIATOR REPORT American LegalNet, Inc. www.FormsWorkFlow.com