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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)