To: Florida Mediation Group

Attention: _________________
 
Fax to: 305.579.9991

______________________________________
     Plaintiff,
v.
______________________________________
     Defendant.

 

 CASE NO._______________________
 
COUNTY:________________________
 
JUDGE:_________________________
 
TRIAL DATE: ______/______/______
 
TYPE OF CASE:__________________
 

 

  
CL#_______________DOL___/___/___
(Pre-Suit)
1st Your Info: Plaintiff/Defense (Circle One)

Name:_____________________________________________

Firm/Company: ______________________________________

Address: ___________________________________________

__________________________________________________

PH#:______________________ Fax:_____________________
2nd Attorney/Adjuster: Plaintiff/Defense (Circle One)

Name:______________________________________________

Firm/Company: ______________________________________

Address: ___________________________________________

__________________________________________________

PH#:______________________ Fax:_____________________
3rd Attorney/Adjuster: Plaintiff/Defense (Circle One)

Name:______________________________________________

Firm/Company: ______________________________________

Address: ___________________________________________

__________________________________________________

PH#:______________________ Fax:_____________________
4th Attorney/Adjuster: Plaintiff/Defense (Circle One)

Name:______________________________________________

Firm/Company: ______________________________________

Address: ___________________________________________

__________________________________________________

PH#:______________________ Fax:_____________________
  • Does everyone agree to mediate this case? Yes / No (Circle One)
  • If no, should FMG call opposing counsel to gain agreement? Yes / No (Circle One)

Date(s) Requested:

 

Duration:

Mediator(s) Requested:

 

Comments: