SCHEDULING

To process your request please submit the following form.
All fields are required unless otherwise noted.
If you have difficulty when submitting the form,
print the form and fax it to (407) 240-7070

Mediation Request Form

Your Name:
Your E-Mail:
Claimant Info:
Name:
OJCC #:
DOA:
Claimant Attorney Info:
Name:
Phone:
Employer Info:
Employer Name:
Carrier Info:
Carrier Name:
Employer/Carrier Attorney:
Name:
Phone:
Location and Time Request:
City:
Address:
Date:
Time:
Please enter any other comments or notes you think will be helpful, including alternative dates, location preferences, any parties attending by phone, etc.
Comments:

All Information Submitted will be reviewed and the mediation location, date and time will be confirmed. Please Note: Your mediation date is not guaranteed until it is confirmed by E-mail or Fax.