Intake Form Step 1 of 4 25% Are you an Attorney or a Client Attorney Client Name* First Last Email* Lawsuit Filed? Yes No Case #Mediation to be Held Online? Yes No PLAINTIFF/CLAIMANT INFORMATIONPlaintiff/Claimant Name*Plaintiff's Counsel Name*FirmEmail Address*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Work PhoneFaxDEFENDANT INFORMATIONDefendant's Name*Company DEFENDANT'S COUNSEL:Defendant's Counsel Name*FirmEmail* Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work PhoneFax INSURANCE CARRIERCarrier NameAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneClaim RepresentativeCASE NAMECASE NUMBER GENERAL QUESTIONSHave all parties agreed to the assignment of Wendy Fassberg as the neutral?How many hours would you like to allocate to this matter? (mediations are booked on a full day/half day basis)How will the fees be split?Are there any time constraints relative to commencement or completion of the mediation?What type of case is this (e.g. Real Estate, Construction, Contract, etc.)?Please provide any other pertinent information below.
