Request Names

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 contact@primedispute.com

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 provide three names of Neutrals (Arbitrators, Mediators, etc). The information submitted on this application is accepted as being accurate and complete. Neither Prime Dispute or the appointed Neutrals accept any liability, 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 selected.

NAMES OF THREE NEUTRALS* (PLEASE SELECT AS APPROPRIATE):

* Indicates required field

Neutral(s) required: *

Other, please specify: *

INFORMATION ABOUT THE DISPUTE

Please provide details regarding the issues concerned: *

Amount in dispute (if appropriate): *

Any applicable time limits: *

PARTIES & THEIR REPRESENTATIVES

Claimant/First Party *

Claimant/First Party - Address *

Line 1

Line 2

City

State

Zip Code

Country

Respondent/Second Party *

Respondent/Second Party - Address *

Line 1

Line 2

City

State

Zip Code

Country

Claimant/First Party - Telephone *

Claimant/First Party - Email *

Claimant(s) Representative - Title *

Claimant(s) Representative - Name *

First

Last

Respondent/Second Party - Telephone *

Respondent/Second Party - Email *

Respondent(s) Representative - Title *

Respondent(s) Representative - Name *

First

Last

Claimant(s) Representative - Firm Name *

Claimant(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 - Preference for the Neutrals background and skills (if any) - This could include; knowledge, profession, professional specialist expertise, experience required: *

Respondent(s) Representative - Firm Name *

Respondent(s) Representative - Address *

Line 1

Line 2

City

State

Zip Code

Country

Respondent(s) Representative - Telephone *

Respondent(s) Representative - Direct Line *

Respondent(s) Representative - Email *

Respondent(s) Representative - Preference for the Neutrals background and skills (if any) - This could include; knowledge, profession, professional specialist expertise, experience required: *

AGREEMENT
Please agree to either part A or B below:

Please agree to either part A or B below: *

Part A - The Parties hereby apply to Prime Dispute to suggest the names of three Neutrals*, for prospective appointment as requested, in a dispute which has arisen between the parties. It is agreed as a condition of Prime Dispute fulfilment of this mandate: To pay the reasonable fees and expenses of the Neutral To inform the Neutral in the event of the settlement of the dispute before the matter has concluded; and That it is acknowledged that Prime Dispute is not liable, by reason of having suggested the Neutral(s), for anything done or omitted to be done by the Neutral in the discharge or purported discharge of his/her functions. Part B - The Applicant hereby apply to Prime Dispute to suggest the names of three Neutrals*, for prospective appointment as requested, in a dispute which has arisen between the parties. It is agreed as a condition of Prime Dispute fulfilment of this mandate: To pay the reasonable fees and expenses of the Neutral To inform the Neutral in the event of the settlement of the dispute before the matter has concluded; and That it is acknowledged that Prime Dispute is not liable, by reason of having suggested the Neutral(s), for anything done or omitted to be done by the Neutral in the discharge or purported discharge of his/her functions.

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 *

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:

Please tick if you agree - This application form is the contract between the applicant and Prime Dispute. Prime Dispute will rely entirely upon the information contained herein to provide three names of Neutrals (Arbitrators, Mediators, etc). The information submitted on this application is accepted as being accurate and complete. Neither Prime Dispute or the appointed Neutrals accept any liability, 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 selected. *

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

CONTACT US | JOIN PRIME DISPUTE

About Prime Dispute

Prime Dispute / Is a global membership organisation for qualifications and standards in law, dispute avoidance, management & resolution

Our purpose / Helping industry create a more prosperous and conflict free working world.

Our Vision & Mission

Insights
Authority
Academy
Regulation
Membership
News
Events
Contract Clauses
Industries
Contact

Terms & Conditions | User Agreement | Business Ethics and Conflict of Interests Policy

Please email all correspondence to contact@primedispute.com

71-75, Shelton Street, Covent Garden, London, WC2H 9JQ, United Kingdom

APPLICATION FORMRequest for Three Names

APPLICATION FORM
Request for Three Names