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Michael Geigerman Case Information Form (Adobe® Acrobat Required, get it here)

Mediation Date
Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ,


Case Name



Case Type
Automobile
Bodily Injury/Personal Injury
Commercial
Construction
FELA
Employment

If Other




Brief Description of Case



Date of Injury/Loss
Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ,


Liability an Issue?
Yes No


Comparative an Issue?
Yes No


Specials
Medical $

Lost Wages $

Amount of Chiro $

Included in Medical?
Yes No


Number of Plaintiffs?


Are there any Minors?
Yes No

If yes, how many?

Number of Defendants?



Venue


Case Number


Are There Any Trial Dates or Time Limitations?
Yes No


Last Offer
$

Last Demand
$

Who Made Last Offer/Demand?



Are There Any Settlement Authority Issues?
Yes No


Do You Have Sufficient Information to Settle This Case?
Yes No

If no, describe what is needed...


Describe the Problems That Have Prevented Settlement



Please Identify Any Special Issues the Mediator Should be Informed of



Names and Titles of Parties and/or Representatives Who Will be Appearing for Plaintiff



Names and Titles of Parties and/or Representatives Who Will be Appearing for Defendant



Date Submitted
Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ,


Prepared by



Attorney For



E-mail Address

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