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:

    PlaintiffDefendant

    Other Parties and Representatives:

    Name (required)

    PlaintiffDefendant

    Represented by:

    Firm Name:

    Telephone:

    Fax:

    Email

    Mailing Address

    Name

    PlaintiffDefendant

    Represented by:

    Firm Name:

    Telephone:

    Fax:

    Email

    Mailing Address

    Name

    PlaintiffDefendant

    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?: yesno

    Forum/Court:

    Trial/Hearing Date:

    Other Key Dates:

    Have all parties agreed to mediation?:
    yesno

    If no, please explain:

    Fees & Expenses to be paid by :
    50/50 SplitReferring PartyOther

    Requested mediation date(s):

    Full Day MediationHalf Day Mediation

    Special Instructions/Comments: