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Mediation Request Form

    Three Step Case Form

    *Indicates required field

    Step 1. Party Information

    a. Plantiff Attorney Name*
    Firm Name*
    Phone Number*
    Email*
    Representing*
    b. Defense Attorney Name*
    Firm Name*
    Phone Number*
    Email*
    Representing*
    c. Claims Representative Name*
    Insurance Company*
    Phone Number*
    Email*
    Representing*
    d. Other Party Name*
    Firm or Company Name*
    Phone Number*
    Email*
    Representing*

     

    Step 2. Case Information

    Case Caption*
    Court Case Number*
    Claim Number*
    Requesting*

     

    Step 3. Upload Documents

    Have all parties agreed to use Mediators Worldwide?*
    Name of neutral selected:*
    Name in case of other*

     

    Please Upload your files*


    Max. file size: 20MB (Acceptable file types: pdf, doc, docx, ppt, pptx, jpg, jpeg, gif, png)