Request for Appointment of a Mediator

Guidance Note - Prior to completing the application:

Please complete this application form and click 'Submit'. If you would like to discuss your application with somebody within our Dispute Resolution team, please email [email protected]

Please complete this form by typing in the required fields.

Please view the 'Schedule of Fees for all Cases' on our website regarding the application fee www.primedispute.com

This application form is the contract between the applicant and Prime Dispute. Prime Dispute will rely entirely upon the information contained herein to help select a Mediator. The information submitted on this application is accepted as being accurate and complete. Neither Prime Dispute or the appointed Mediator accept liability in relation to the appointment, if the information provided is inaccurate or incomplete.

Please do not complete this form if you don't want Prime Dispute to collect, store, share with the Mediator and process your information. Please note - Prime Dispute will give careful consideration to any representations, but will reach its own decision as to who is appointed.

REQUESTING THE APPOINTMENT OF* (PLEASE SELECT AS APPROPRIATE):

* Indicates required field

Neutral(s) required: *

If 'Other' please specify: *

INFORMATION ABOUT THE DISPUTE

Please provide details regarding the issues concerned: *

Amount in dispute (if appropriate): *

Preferred location for the meeting (if any): *

Any applicable time limits: *

PARTIES & THEIR REPRESENTATIVES
Prime Dispute will take reasonable steps to ensure that the appointed Mediator is free from conflict of interests. It is therefore essential that you provide details of the parties and their representatives.

The parties representatives must be stated. Where a party is unrepresented, please ensure email addresses are included (if you have a direct contact number, please also include this). Communications from Prime Dispute are sent by email. Therefore, it is important you provide email addresses.

Claimant/First Party *

Claimant/First Party - Address *

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Line 2

City

State

Zip Code

Country

Respondent/Second Party *

Respondent/Second Party - Address *

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Line 2

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State

Zip Code

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Claimant/First Party - Telephone *

Claimant/First Party - Additional parties: *

Claimant/First Party - Email *

Claimant(s) Representative - Title *

Claimant(s) Representative - Name *

First

Last

Claimant(s) Representative - Firm Name *

Prime Dispute Member (please state designation, i.e FPD,etc) : *

Claimant(s) Representative - Address *

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Line 2

City

State

Zip Code

Country

Respondent/Second Party - Telephone *

Respondent/Second Party - Additional parties: *

Respondent/Second Party - Email *

Respondent(s) Representative - Title *

Respondent(s) Representative - Name *

First

Last

Respondent(s) Representative - Firm Name *

Prime Dispute Member (please state designation, i.e FPD,etc) : *

Respondent(s) Representative - Address *

Line 1

Line 2

City

State

Zip Code

Country

Claimant(s) Representative - Telephone *

Claimant(s) Representative - Direct Line *

Claimant(s) Representative - Email *

Claimant(s) Representative - Are you the referring party *

Yes No Other

If 'Other' please specify *

Claimant(s) Representative - Preference for the Mediator(s) background and skills (if any): *

Respondent(s) Representative - Telephone *

Respondent(s) Representative - Direct Line *

Respondent(s) Representative - Email *

Respondent(s) Representative - Are you the referring party *

Yes No Other

If 'Other' please specify *

Respondent(s) Representative - Preference for the Mediator(s) background and skills (if any): *

AGREEMENT
Please agree to either part A or B below:

Please agree to either part A or B below: *

Part A - Unilateral application for the appointment of an Mediator. An agreement between the parties dated (please state below) allows for or includes the provision that in the event of a dispute, either party may apply to Prime Dispute to appoint a Mediator in the matter: A copy of said provision of the agreement, and particulars of the dispute, are attached and clearly marked. Any condition precedent to the right of either party to make a unilateral application for the appointment of a Mediator has been satisfied and particulars of this, if any, are attached. It is agreed as a condition of such an appointment: To pay the reasonable fees and expenses of the Mediator, whether or not any agreement is reached during mediation; To provide adequate security for such payment if the Mediator so requests; To inform the Mediator in the event of the settlement of the dispute before any Mediation takes place; and That it is acknowledged that Prime Dispute is not liable, by reason of having appointed or nominated the Mediator, for anything done or omitted to be done by the Mediator in the discharge or purported discharge of his/her functions. Part B - Joint Application for the appointment of a Mediator. The parties hereby apply to Prime Dispute for their dispute (particulars of which are attached), to be referred to Mediation by a Mediator appointed for that purpose by Prime Dispute. It is agreed as a condition of such an appointment: To pay the reasonable fees and expenses of the Mediator, whether or not any agreement is reached during mediation; To provide adequate security for such payment if the Mediator so requests; To inform the Mediator in the event of the settlement of the dispute before any Mediation takes place; and That it is acknowledged that Prime Dispute is not liable, by reason of having appointed or nominated the Mediator, for anything done or omitted to be done by the Mediator in the discharge or purported discharge of his/her functions.

If you selected 'Part A' (from the above list) please provide the date of the agreement between the parties. If not applicable please state "N/A": *

Upload File *

Max file size: 20MB

FEE

Payment will be required once your application has been received and acknowledged by the Executive at Prime Dispute (please select): *

Pay Online Receive and invoice and pay directly Other

If 'Other' please specify *

Please note: Once you submit your application, it will be sent to our Executive to review. The invoice will include the name and address you have provided above. If you prefer an alternative name or department within the organisation to be named, please specify: *

PRIVACY
Prime Dispute takes the privacy and security of the personal information you provide seriously. Your details are held in a secure database with access provided to senior Prime Dispute Executives only. We apply data processing policies in compliance with the Data Protection Act 2018. Prime Dispute will not use the information you provide in this request to contact you with offers of products and services. Prime Dispute will not share your information with third parties for the purpose of sending you details of offers of products or services. Please read our Terms and Conditions on our website.

FINAL STAGE - APPLICATION SUBMITTED BY:

This application form is the contract between the applicant and Prime Dispute. Prime Dispute will rely entirely upon the information contained herein to help select an Arbitrator. The information submitted on this application is accepted as being accurate and complete. Neither Prime Dispute or the appointed Arbitrator accept liability in relation to the appointment, if the information provided is inaccurate or incomplete. Please do not complete this form if you don't want Prime Dispute to collect, store, share with the neutral(s) and process your information. Please note - Prime Dispute will give careful consideration to any representations, but will reach its own decision as to who is appointed. *

I agree

Title *

Full Name *

First

Last

Firm name: *

Please specify who you are applying on behalf of (e.g ‘Claimant’, ‘Respondent’): *

Date: *

Email *

Upload File *

Max file size: 20MB

Upload File *

Max file size: 20MB

Upload File *

Max file size: 20MB

Upload File *

Max file size: 20MB

Submit

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REQUEST FOR THE APPOINTMENT OF A MEDIATOR