Referring Party:
Plaintiff Counsel
Defence Counsel
Insurer
Date of Incident:
Plaintiff's Name(s):
Plaintiff Counsel:
Law Firm:
Phone:
Fax:
File #:
Defendant's Name(s):
Defence Counsel (if applicable) :
Law Firm:
Phone:
Fax:
File #:
Adjuster's Name:
Insurance Company:
Phone:
Fax:
Claim #:
Briefly describe the nature of this dispute and any negotiations that have taken place so far:
What issues are in dispute?
Quantum
Liability
Other:
Timing expectations:
Mediator preferences:
Fee arrangements:
Not discussed
Both parties agree to share the costs
Defendant agrees to cover all costs
Other:
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this information, we recommend you call or fax us the details of your referral.
Thank you!
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"submit" then please print the completed form and fax it to (403) 226-0725 or (780) 484-3484.)
Copyright 2004 Canadian Dispute Resolution Co. Inc.
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