Submit Case

Instructions: To submit a case to MDRS you can call us at 800-536-5520 and submit case information by telephone to our Case Manager, OR you can complete the electronic form below and email it to us.

Upon receipt, we will contact you to finalize the case submission, answer any questions you may have, and MDRS will do all that is necessary thereafter to contact all parties and schedule the matter for a convenient mediation session or arbitration hearing.

MDRS CASE SUBMISSION
Submitted By:
Email Address:
Case Name:
VS.
 
Type of Case:
   
 
PLAINTIFF INFORMATION:
DEFENDANT INFORMATION:
# of Witnesses
# of Witnesses
Name:
Name:
Name:
Name:
Plantiff Attorney:
Defendant Attorney:
Address:
Address:
Phone:
Phone:
Fax:
Fax:
Insurance Co:
Insurance Co:
Claim Number:
Claim Number:
 
Services Requested:
Mediation: Arbitration: High-Low Arbitration:
Other, please specify:
 
Preferred dates & location:
 
Preferred Neutral(s):
 
Please list any further comments below or on a separate sheet: