ATTORNEY ' S CONFIDENTIAL INFORMATION SHEET AND REQUEST FOR MEDIATION

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; (c) substantially complete; or (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: _____________________________