Request to Mediate
Request to Mediate
__________________________ __________________________ __________________________ [Name and address of signatory company]
Attention: Claims Department
Re: ___________________ [Claimant) ___________________ [Name of Insured or Potential Defendant] ___________________ [Claim Number if Known or Appropriate] ___________________ [Date of Accident or Loss, if Appropriate]
To Whom It May Concern:
It is my understanding that this company is a signatory to the _____________________ Pre-Suit Mediation Program. I have read and understand the Program Instructions and the Signatory Position Statement, and hereby agree to abide by the terms thereof with respect to this claim.
I understand _____________________ sponsors and endorses the Program for the purpose of achieving its stated goal. The ______________________ role in the Program, however, is merely one of facilitating the selection of mediators and scheduling mediation conferences. By voluntarily participating in the Program, I accept and recognize that the _______________________ shall have no liability, express or implied, with respect to any aspect of the Program, including the actions of a mediator.
I understand that participating in mediation may affect my legal rights regarding my claim and my right to file a lawsuit at a later date. I understand that the ___________________ recommends that I consult with an attorney of my choice prior to any pre-suit mediation. I understand that the _______________________________ will not furnish me with a lawyer. Upon request, I understand that the __________________________ lawyer referral program will refer me to a lawyer.
I understand that _______________ of the mediator’s fee (not to exceed $____________) will be paid by the company, and _______ be paid by me, prior to the mediation session, unless alternative arrangements are made. In the event the mediator’s fee exceeds _________ the parties will split equally any additional amounts. By copy of this letter to the _____________________, I am forwarding the ______ administrative fee and am requesting that list of ___ mediators be sent to you and the undersigned in order to commence the mediation process.
__________________________________ [Claimant]
__________________________________ __________________________________ [Address] __________________________________ [Telephone Number]
__________________________________ [Claimant’s Attorney, if applicable]
__________________________________ __________________________________ [Address]
__________________________________ [Telephone Number]
A Copy of the foregoing Request to Mediate has been mailed with a $_______________ check payable to the _________________________ on this the ____ day of __________ _________, 19__, to _________________________________________.
_____________________________________ [Claimant or Claimant’s Attorney]
© 1996 The Mediation Center, Inc.
