Mediation Inquiry/Request

Mediation Inquiry/Request

Your Name (required)

Your Firm (required)

Your Telephone Number (required)

Your Fax Number

Your Email (required)

Mailing Address

Case Name

Your Client:

 Plaintiff Defendant

Other Parties and Representatives:

Name (required)

 Plaintiff Defendant

Represented by:

Firm Name:

Telephone:

Fax:

Email

Mailing Address

Name

 Plaintiff Defendant

Represented by:

Firm Name:

Telephone:

Fax:

Email

Mailing Address

Name

 Plaintiff Defendant

Represented by:

Firm Name:

Telephone:

Fax:

Email

Mailing Address

Type of Case/Dispute (description required)

Amount of Claim: (required)

Amount of Counterclaim: (required)

Litigation/Arbitration?:  yes no

Forum/Court:

Trial/Hearing Date:

Other Key Dates:

Have all parties agreed to mediation?:
 yes no

If no, please explain:

Fees & Expenses to be paid by :
 50/50 Split Referring Party Other

Requested mediation date(s):

 Full Day Mediation Half Day Mediation

Special Instructions/Comments: