<p> INTERNATIONAL DISPUTE RESOLUTION CENTRE 70 FLEET STREET Independent LONDON, EC4Y 1EU tel: +44 (0)20 7127 9223 Mediators fax: 0845 557 5926 e-mail: [email protected] web: www.independentmediators.co.uk</p><p>PLEASE REPLY TO: Mediation Information Form ADMINISTRATION OFFICE WREST PARK ENTERPRISE CENTRE, 52 WREST PARK, (please type) SILSOE, BEDFORDSHIRE, MK45 4HS</p><p>NAME OF MEDIATOR (please state):______</p><p>1 Name and address Please list Claimant(s) first and of Parties to Defendant(s) in following boxes Dispute Party A Address</p><p>Party B Address</p><p>Party C Address</p><p>2 Party A Solicitors’ Firm’s Name</p><p>Address</p><p>The mediator will, wherever possible, contact the solicitor with conduct of the matter prior to the mediation. Please provide contact details to include name, email address and direct dial telephone number below</p><p>Independent Mediators www.independentmediators.co.uk Contact DX Direct Dial Tel Fax e-mail </p><p>Attendees: Name Firm Position (inc counsel, solicitors, party)</p><p>3 Party B Solicitors’ Firm’s Name</p><p>Address</p><p>The mediator will, wherever possible, contact the solicitor with conduct of the matter prior to the mediation. Please provide contact details to include name, email address and direct dial telephone number below Contact DX Direct Dial Tel: Fax: e-mail</p><p>Attendees: Name Firm Position (inc counsel, solicitors, party)</p><p>4 Party C Solicitors’ Firm’s Name</p><p>Address The mediator will, wherever possible, contact the solicitor with conduct of the matter prior to the mediation. Please provide contact details to include name, email address and direct dial telephone number below Contact DX Direct Dial Tel: Fax: e-mail</p><p>Attendees: Name Firm Position (inc counsel, solicitors, party)</p><p>5 Present Position a) Court directed? Yes/No b) All parties agreed to Yes/No mediate?</p><p>6 The Dispute Court Reference Number: Issuing Court:</p><p>Please state the brief nature of the dispute (full details will be taken later)</p><p>7 The Claim a) Standard Value of £ claim* b) Is there a counter £ claim – value?*</p><p>8 Date of mediation</p><p>9 Location</p><p>10 Where did you hear about our mediation services</p><p> If the value of the claim and counterclaim are materially higher than those notified above when the Mediation Case Summaries are received by the Mediator the fees may be adjusted accordingly</p>