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800-844-4237

500 N. Broadway, Suite 1800 Saint Louis, MO 63102

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New Mediator Form

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New Mediator Form

New Mediator Forms

Name:

Name:

First

First

Last

Last

Address:

Home Phone:

Cell Phone:

Email:

Emergency Contact:

Emergency Contact:

First

First

Last

Last

Emergency Contact Phone:

Spouse’s Name:

Spouse's Name:

First

First

Last

Last

Spouse’s Cell Phone:

Birthdate:

Mediation Hourly Rate (including $150 override):

Are you interested in serving as an Arbitrator?

Yes

No

Arbitration Hourly Rate (including $150 override):

Are you interested in participating in our Flat Fee Mediation program (*see below for details)?

Yes

No

Do you want us to print you business cards?

Yes

No

If yes, do you want your cell number and/or email printed?

Yes, print cell number

Yes, print email

No, to both cell and email

Would you like USA&M to keep your calendar?

Yes

No, call me for my availability

No, email me for my availability

Do you have malpractice insurance?

Yes

No, I would like to enroll in USA&M’s policy

Admiralty/Jones Act

Advertising/Media/Communications

Banking

Bankruptcy

Business/Commercial

Civil Rights

Class Action/Mass Tort

Complex Litigation

Constitutional Law

Construction

Contract

Corporate Partnership Disputes

Elder Law

Employment/ADA/Discrimination

Employment Benefits

Environmental/Toxic Tort

Family Law

FELA

Flat Fee Mediation Program *see below for details

Franchise/Securities

Healthcare

Home Foreclosure

Insurance Policy Disputes

Intellectual Property

Legal Malpractice

Medical Malpractice

Nursing Home Negligence

Personal Injury (Auto/Trucking/Etc)

Premises Liability

Product Liability

Professional Malpractice

Property Damage

Real Estate

School

Sexual Misconduct

Subrogation

Tax

Title IX

Unfair Competition

Uninsured Motorist

Will/Trust/Probate

Workers Comp

Wrongful Death

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Areas of Practice:

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.

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