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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)