Mediation Referral

Please list the names of all parties and counsel

If suit has not been filed, please complete the following

Please fill out this form in order to refer a case to mediation

Special Instructions: If you have a deadline for mediation, a request for a particular mediator, a specific date for the mediation or other special instructions, please indicate below:

Your name:

Your phone number:

Your email address:

County

Case No.

Style of case:

vs.

City:

Claim Number:

Insurance Carrier:

Date of Loss:

Adjuster:

Address of Adjuster:

Zip:

State:

Phone number:

Are the parties splitting the mediation fee?:

If no, how will the fee be paid?:

Plaintiff Counsel:

Address:

City:

Zip:

State:

Phone number:

Defense Counsel:

Address:

City:

Zip:

State:

Phone number:

Other Counsel:

Address:

City:

Zip:

State:

Phone number:

If there are additional counsel please list below:
(please advise which party each attorney represents)