Mediation Case Information Form

Date Submitted:

Prepared by:

Your Email Address: *

Mediator:

Mediation Date:

Case Name:

Type of Case:

(ie Personal Injury, Medical Malpractice, etc.)

Brief description of case:

Date of injury/loss:

Liability an issue?

Yes

Comparative an issue?

Yes

Specials incurred: (medical/plus chiro/property damage)

Specials paid and/or owed: (medical/plus chiro/lost wages)

Amount of Medical/WC liens:

Status of medicare lien and medicare set aside, if any:

# of Plaintiffs:

# of Defendants:

Do you want an initial joint session?

Yes

If no initial joint session, please state the reason(s).

Any minors involved?

Yes

Venue:

Judge:

Cause#:

Is case set for trial?

Yes

If it is set for trial, list the date:

Any dispositive motions pending?

Yes

If yes, please describe:

Last offer:

Last demand:

Who made the last offer/demand?

Are there any settlement authority issues?

Yes

If yes, please identify:

Do you have sufficient information to settle this case?

Yes

If not, what is needed?

Please identify and provide any documents you would like the mediator to review:

Describe the issues that have prevented settlement:

Please identify any special issues the mediator should be informed of:

Names and Title of individuals and Representatives who will be appearing for plaintiff:

Names and Title of individuals and Representatives who will be appearing for defendant:

By submitting this form, preparer assures that a client with full authority to establish and change a settlement position and who can sign an agreement which is binding without later ratification, will be present for the entire mediation in addition to counsel (unless alternative agreement has been reached by the parties and the mediator is so advised).

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United States Arbitration & Mediation (USA&M)

Phone: 314-231-4642, 800-844-4ADR (4237) Fax: 314-231-0137 Address: 500 N. Broadway, Suite 1800, Saint Louis, Missouri 63102 Email

NOTE: Nothing contained herein is intended to give legal advice. Individuals should always consult with an attorney before entering into a contract.