Case Submittal Form

Mediation Submittal Form

Submitting the following information at this time will help us to process your referral quickly and efficiently. Please e-mail a proof of service to us, noting which counsel is representing the respective parties, and a caption page. Doing so will enable us to be aware of the identity of all of the parties to the dispute as well as the court¹s case number, so that we may complete a conflicts check, prepare a confirming letter and copy any necessary Court ADR Administrator. We also like to have e-mail addresses for all counsel of record for scheduling the session.

This form is sent through a secure server. You may also print it out and fax it to us at 415-388-1036.

Note: All fields marked with an asterisk (*) are required. Thank you.

This form is sent through a secure server.

Please complete the form below and we will contact you as soon as possible.

Case Submittal Form

Type of Case / Dispute:

Case Name:*

Your principal / insured / client is a:*

Plaintiff Defendant Cross/Defendant Other (Please Describe below)

Other Description:*

Submitting Atty. or Party:*

Address:

City:

Zip:

Country:*

State:

Province:*

Submitting Insurance Carrier:

Your E-Mail:*

Your Phone Number:*

Your Fax:

Other counsel's E-mail address (eg. Name : E-mail address):*