Requesting Party's Name *

First Name

Last Name

Role

Plaintiff

Defense

Adjuster

Plaintiff Attorney's Name *

First Name

Last Name

Defense Attorney's Name *

First Name

Last Name

Claimant's Name *

First Name

Last Name

DOL

MM

DD

YYYY

What type of case is this? *

Workers Comp

Tort

Both

Mediation Fee *

(choose one)

Defense to pay

Parties to split fee unless negotiated otherwise

Defense to pay if resolved; split if unresolved.

Plaintiff Attorney Mailing Address

(for billing purposes)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Defense Attorney Mailing Address

(for billing purposes)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country