Mediation Submission Form

Case Caption

Claimant Name

Court file number (if any)

Representative/Attorney

Firm/Company

Website address

Address

City

State

Zip

Phone

Fax

RESPONDENT Name

Court file number (if any)

Representative/Attorney

Firm/Company

Website address

Address

City

State

Zip

Phone

Fax

INSURANCE INFORMATION

Carrier Name

File/Claim Number

Website address

Address

City

State

Zip

Phone

Fax

OTHER PARTIES TO DISPUTE

NATURE OF DISPUTE – BRIEF DESCRIPTION OF CASE

CASE INFORMATION SUIT FILED?

Yes

COURT

TRIAL DATE

MEDIATION DEADLINE (IF APPLICABLE)

HAVE ALL PARTIES AGREED TO SUBMIT DISPUTE TO MEDIATION?

FEE SPLIT PLAINTIFF/CLAIMANT

DEFENDANT/RESPONDENT

OTHER

SUBMISSION INFORMATION Submitted by

Date

Firm/Company

Address

City

State

Zip

Phone

Fax

Plaintiff Attorney

Defense Attorney

Claim Representative

Other

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All content on this website is intended to provide general information about our mediation services and an opportunity for interested persons to contact us. The content of this website is not offered as legal advice or legal opinion and it should not be relied upon for any specific situation. This website is for informational purposes only and does not constitute a complete description of our services. While we endeavor to keep the information updated and correct, we make no representations or warranties of any kind, express or implied, about the completeness, accuracy, or reliability of the information contained in this website.

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