Mediation Request Form

Mediation Request Form

This Mediation Request Form is submitted by Requesting Party: (Primary Contact: ) and Responding Party: (Primary Contact: ). Date of Request:

RECITALS

WHEREAS, the Requesting Party and the Responding Party (collectively, the Parties) are engaged in a dispute arising out of: ;

WHEREAS, the dispute relates to an agreement, transaction, event, or relationship dated: and identified as: ;

WHEREAS, the Parties seek to resolve the dispute through mediation to avoid litigation and to preserve the Parties' business relationship where possible.

NOW, THEREFORE, in consideration of the mutual promises set forth herein, the Parties agree as follows:

1. APPOINTMENT OF MEDIATOR

1.1 Selection. The Parties agree to refer the dispute to mediation. The Parties propose the following mediator(s) by name and consent to the mediator's disclosure obligations and conflicts check:

1.2 Appointment Procedure. If the Parties cannot agree on a mediator within seven (7) days of the date of this Request, either Party may notify the other in writing and request appointment under the agreed mediation procedure set forth in Section 9.

2. SCOPE OF MEDIATION

2.1 Subject Matter. The Parties agree that the mediation shall address the disputes identified in Section 1 and any related claims reasonably connected to the same transaction or occurrence, including claims for:

3. CONFIDENTIALITY

3.1 Confidentiality Obligation. All communications, offers, proposals, statements, writings, and documents produced for or during the mediation are confidential settlement discussions and shall be inadmissible in any subsequent litigation or arbitration to the fullest extent permitted by law. The Parties agree not to subpoena or otherwise compel the mediator to disclose mediation communications except as required by law.

3.2 Exceptions. Confidentiality shall not apply to information that (a) is or becomes publicly available through no fault of a Party, (b) is independently developed or obtained by a Party outside the mediation, or (c) must be disclosed by statute or court order, provided the disclosing Party gives prompt written notice to the other Party and, if feasible, seeks protective relief.

4. AUTHORITY TO SETTLE

4.1 Representative Authority. Each Party represents and warrants that the individual(s) attending the mediation on its behalf will have full authority to negotiate settlement, or that a person with such authority will be available by telephone or in person during the mediation.

4.2 Corporate or Agency Authorization. If a Party is a corporation, partnership, or other entity, the individual signing this form certifies that they have been authorized to request mediation and, if applicable, to execute settlement documents binding on the entity.

5. FEES AND COSTS

5.1 Mediator Fees. The Parties agree that mediator fees and administrative costs will be allocated as follows (select one or describe alternative allocation):

Equal share by Parties    Requesting Party pays    Responding Party pays

5.2 Estimated Amount. Estimated total mediation fees and costs:

6. PROCEDURES AND SCHEDULING

6.1 Format. The Parties agree that mediation will occur in the following format (check all that apply):

In person    Virtual / Teleconference    Hybrid

6.2 Availability. The Parties submit the following dates on which they are available for mediation:

From:   To:

7. PRIOR SETTLEMENT EFFORTS

8. RELIEF SOUGHT

8.1 Description of Relief. The Requesting Party seeks the following relief:

8.2 Monetary Amount Claimed:

9. MEDIATION RULES

9.1 Applicable Rules. The Parties agree that mediation will be conducted under the Parties' agreed rules. If no specific rules are selected, the mediator's customary procedures will apply.

Select rule basis: Agreed commercial mediation procedure    Court-connected program rules    Ad hoc procedure as directed by the mediator

10. NOTICES

Requesting Party - Notice Address

Responding Party - Notice Address

Notices required under this form shall be in writing and delivered by hand, certified mail, or electronic mail to the addresses set forth above. A notice is effective upon receipt.

11. GOVERNING LAW

This Mediation Request Form shall be governed by and construed in accordance with the laws of: , without regard to conflict of law principles.

12. ENTIRE AGREEMENT

This form constitutes the entire mediation request agreement between the Parties with respect to the subject matter hereof and supersedes all prior understandings, whether oral or written, relating to the arbitration/mediation referral described herein.

13. SEVERABILITY

If any provision of this Form is held to be invalid, illegal, or unenforceable in any respect, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or impaired thereby.

14. AMENDMENTS; WAIVER; COUNTERPARTS

Any amendment to this Form must be in writing signed by both Parties. Failure or delay by either Party in exercising any right under this Form shall not operate as a waiver of that right. This Form may be executed in counterparts, each of which shall be an original and all of which together shall constitute one instrument.

15. CERTIFICATION

By signing below, each Party certifies that the information provided in this form is true and correct to the best of their knowledge; that they request good faith participation in mediation; and that they understand and accept the confidentiality, fee, and authority provisions set forth above.

Sign Now