To submit a case for mediation, please complete the following form. 

After receiving the case submission form, USA&M will solicit agreement.  USA&M provides the mediator and the venue and obtains the parties’ agreement to mediate.   For mediations there is no filing fee and no charge if we are unable to get the necessary parties agreement to participate. 

We structure our process to facilitate closing files, not to increase your workload.  You do not have to get the other side to agree before sending us the case.

Feel free to contact us with any questions you may have.

All fields for Parties 1 & 2 are required.
Fields for Parties 3 through 8 are only required if more than 2 parties are participating in the mediation.

Medication Case Submission Form (Adobe® Acrobat Required, get it here)

Party 1

Party 1 Full Name
Party 1 Role	choose a role Plaintiff Defendant Plaintiff/3rd Party Defendant Defendant/3rd Party Plaintiff 3rd Party Defendant
Counsel Full Name
Counsel Address
Counsel Address 2
Counsel City
Counsel State	choose a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Counsel Zip
Counsel Telephone
Counsel Fax
Counsel Email

Party 2

Party 2 Full Name
Party 2 Role	choose a role Plaintiff Defendant Plaintiff/3rd Party Defendant Defendant/3rd Party Plaintiff 3rd Party Defendant
Counsel Full Name
Counsel Address
Counsel Address 2
Counsel City
Counsel State	choose a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Counsel Zip
Counsel Telephone
Counsel Fax
Counsel Email

If there are no additional parties, click here.

Othewise, proceed below...

Party 3

Party 3 Full Name
Party 3 Role	choose a role Plaintiff Defendant Plaintiff/3rd Party Defendant Defendant/3rd Party Plaintiff 3rd Party Defendant
Counsel Full Name
Counsel Address
Counsel Address 2
Counsel City
Counsel State	choose a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Counsel Zip
Counsel Telephone
Counsel Fax
Counsel Email

Party 4

Party 4 Full Name
Party 4 Role	choose a role Plaintiff Defendant Plaintiff/3rd Party Defendant Defendant/3rd Party Plaintiff 3rd Party Defendant
Counsel Full Name
Counsel Address
Counsel Address 2
Counsel City
Counsel State	choose a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Counsel Zip
Counsel Telephone
Counsel Fax
Counsel Email

Party 5

Party 5 Full Name
Party 5 Role	choose a role Plaintiff Defendant Plaintiff/3rd Party Defendant Defendant/3rd Party Plaintiff 3rd Party Defendant
Counsel Full Name
Counsel Address
Counsel Address 2
Counsel City
Counsel State	choose a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Counsel Zip
Counsel Telephone
Counsel Fax
Counsel Email

Party 6

Party 6 Full Name
Party 6 Role	choose a role Plaintiff Defendant Plaintiff/3rd Party Defendant Defendant/3rd Party Plaintiff 3rd Party Defendant
Counsel Full Name
Counsel Address
Counsel Address 2
Counsel City
Counsel State	choose a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Counsel Zip
Counsel Telephone
Counsel Fax
Counsel Email

Party 7

Party 7 Full Name
Party 7 Role	choose a role Plaintiff Defendant Plaintiff/3rd Party Defendant Defendant/3rd Party Plaintiff 3rd Party Defendant
Counsel Full Name
Counsel Address
Counsel Address 2
Counsel City
Counsel State	choose a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Counsel Zip
Counsel Telephone
Counsel Fax
Counsel Email

Party 8

Party 8 Full Name
Party 8 Role	choose a role Plaintiff Defendant Plaintiff/3rd Party Defendant Defendant/3rd Party Plaintiff 3rd Party Defendant
Counsel Full Name
Counsel Address
Counsel Address 2
Counsel City
Counsel State	choose a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Counsel Zip
Counsel Telephone
Counsel Fax
Counsel Email

Case Information

All fields required.

Case Type
Select Admiralty/Jones Act Banking Business/Commercial Civil Rights Class Action/Mass Tort Construction Contracts Corporate Dispute/Dissolution Franchise/Securities Employment/ADA/Discrimination Envrionmental/Toxic Tort FELA Insurance Policy Disputes Intellectual Property Personal Injury Personal Injury Auto Premises Liability Product Liability Professional Malpractice Property Damage Real Estate Subrogation Will/Trust/Probate Other


If Other, Please Name...



Is This Case in Suit?
Yes No

If Yes, Which Venue/Court?


Cause Number


Last Demand $

Last Offer $

Specials $


Has a Mediator Been Selected by the Parties?
Yes No

If Yes, Which One(s)?



Have any Available Dates Been Identified?
Yes No

If Yes, Which One(s)?


Submitted By


Attorney For
choose a role Plaintiff Defendant Plaintiff/3rd Party Defendant Defendant/3rd Party Plaintiff 3rd Party Defendant

E-mail Address

720 Olive Street, Suite 2300, Saint Louis, Missouri

Copyright 2006 United States Arbitration & Mediation Midwest, Inc.