Request to Initiate Mediation

Interested in mediation?

Complete the request to initiate mediation form. You may download and mail the completed form to UpSide413.

Names of All Parties in the Dispute

First Name of Party Requesting Mediation *

Last Name of Party Requesting Mediation *

Email *

Phone number *

Fax number

Professional Liability Insurance Company

Name of Legal Counsel or Other Representative

Name of Firm

Counsel Address

Counsel Phone

Counsel Fax

Other Party Name

Other Party Email

Other Party Address

Professional Lability Insurance Company (if known)

Name of Legal Counsel or other Representative (if known)

Name of Firm

Counsel Address

Counsel Phone

Counsel Fax

Other Party Name #2

Other Party Email

Other Party Address

Professional Lability Insurance Company (if known)

Name of Legal Counsel or other Representative (if known)

Name of Firm

Counsel Address

Counsel Phone

Counsel Fax Number

Brief Description of Claim *

Amount of Money Involved *

Have there been any formal court pleadings filed in this case?

yes

no

If yes, are there any trial dates or time limitations involved?

yes

no

Trial date

Court

County

Judge

Court Case Number

Do you have authority to enter into and sign a binding written agreement to settle this on behalf of the party you represent? *

yes

no

Comment

Do you need additional information from another attorney?

yes

no

If yes, what?

Prior Mediation

Has a prior agreement to mediate been signed by the parties?

Yes

No

If yes, please attach copy of the signed agreement.

Yes

No

Thank you for your request. We will be follow-up with you.

There was an error trying to send your request. Please try again later.

Request to Initiate Mediation

Interested in mediation?

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