Alternative Dispute Resolution (ADR) Request for Mediation or Arbitration

Requested ADR Process(Required)

Mediation

Family Law Mediation

Arbitration

Is your matter currently in litigation?(Required)

Yes

Case Name

Case Number

Judge Assigned

Type of Case

Ex., personal injury, malpractice, contract, etc.

Plaintiff

Attorney

Address

Street Address Address Line 2 City State ZIP Code

Phone

Insurance Carrier

Name

Attorney

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Insurance Carrier

If more than two parties, please provide additional information here.

Preferred Mediator/Arbitrator

Optional