4. If an insurance company is involved, please provide the following:
, one or more of the parties in the above cause, the undersigned attorney of record requests that W. Jerry Hoover ( "Mediator" ), agree to serve as mediator in the above case. My client(s) and I have read and agree to be bound by the rules of mediation attached hereto as well as by all procedural rules established by the mediator. I HAVE ADVISED MY CLIENT(S) THAT THE MEDIATOR, INCLUDING HIS STAFF, DOES NOT SERVE AS COUNSEL TO ANY PARTY AND THAT EACH PARTY MUST RELY EXCLUSIVELY ON THEIR OWN COUNSEL FOR ALL LEGAL ADVICE.