Fassberg Mediation Services | Intake Form - Fassberg Mediation Services

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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.

Intake Form