22287 Mulholland Highway, #185 Calabasas, CA 91302
818-222-5025
wfassberg@fassbergmediation.com
Fassberg Mediation Services
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Are you an Attorney or a Client
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Attorney
Client
Name
*
First
Last
Email
*
PLAINTIFF/CLAIMANT INFORMATION
Name
Company
Email Address
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Work Phone
Fax
PLAINTIFF'S COUNSEL:
DEFENDANT INFORMATION
Name
Company
Email Address
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Work Phone
Fax
DEFENDANT'S COUNSEL:
PLAINTIFF/CLAIMANT INFORMATION:
Name
Company
PLAINTIFF'S COUNSEL
Name
Firm
Email
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Work Phone
Fax
DEFENDANT INFORMATION:
Name
Company
DEFENDANT'S COUNSEL:
Name
Firm
Email
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Fax
INSURANCE CARRIER
Carrier Name
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Telephone
Fax
Claim Representative
Claim Number
CASE NAME
CASE NUMBER
GENERAL QUESTIONS
Have all parties agreed to the assignment of Wendy Fassberg as the neutral?
Yes
No
How many hours would you like to allocate to this matter? (mediations are booked on a full day/half day basis)
How will the fees be split?
Are there any time constraints relative to commencement or completion of the mediation?
Yes
No
What type of case is this (e.g. Real Estate, Construction, Contract, etc.)?
Please provide any other pertinent information below.
Email
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