Confidential Information Sheet

THE ATTORNEYS CONFIDENTIAL INFORMATION SHEET AND REQUEST FOR MEDIATION

Name(Required)

Phone(Required)

Email(Required)

Cause No:

Style:

Court/Judge/Arbitrator:

Trial/Arbitration Date:

1. Your firm name, address, telephone and fax numbers:

2. Name and designation (e.G. Plaintiff, defendant, intervenor, etc) of Party you represent:

3. Name of your party representative(s) (other than the attorney of record) to attend the mediation:

4. If an insurance company is involved, please provide the following:

a. Name of Company:

b. Adjuster or other representative you will be bringing:

c. Policy limits:

d. Anything unusual or noteworthy:

5. Summarize the nature of the case and the most contentious issues:

6. State the specific relief in dollars being sought by any party seeking to affirmatively recover:

7. Provide the history of settlement offers to date and the current status of settlement dialogue:

8. What is the status of discovery? (circle one):

(a) little or none;

(b) some discovery but substantially incomplete;

(d) complete;

9. Do you have sufficient information to form a realistic settlement position? If not, what else is needed?

10. Additional information for Mediator (if any) :

11. Motions Pending:

12. Total number of people in your party who will be attending the mediation:

On Behalf of

, 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.

Dated

on the __________ day of _____________________, 20___.

Respectfully submitted,

Attorney of Record

Print Name:

Phone

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