Attorney or Party Without Counsel (Name and Address): Attorney for (Name): Telephone No: Plaintiff Defendant For Court Use Only: Cross-defendant SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES 111 North Hill Street, Los Angeles, California 90012 PLAINTIFF(S): CASE NUMBER DEFENDANT(S): EARLY MEDIATION STATUS CONFERENCE STATEMENT (For Pilot Program Cases, in lieu of Initial Status Conference Questionnaire) Early Mediation Status Conference Date: NOTICE: Each party is required to complete this Statement, serve copies on all other Time: parties and on the ADR Office, and file the original in the Department where the Early Mediation Status Conference (EMSC) is scheduled at least 5 court days before the EMSC. Dept: 1. 2. This Statement is filed on behalf of (names) (check all that apply) Plaintiff or Defendant or Petitioner........ Respondent........ CrossComplainant ........ 3. Is any party representing him or herself in this action? Yes ........................ No ........................ CrossDefendant ........ Other............. Is any party on whose behalf this Statement is filed being defended by an insurance carrier? Yes ........................ No ........................ 4. Date action filed: 5. Date party filing this Statement appeared: 6. Have all parties named in your affirmative pleading been served? N/A .......... No ............ Yes ........... 7. Have all parties named in your affirmative pleading answered or been defaulted? Yes ........... No ............ N/A .......... 8. Identify any parties named in your pleading that have not yet been served, or have not appeared or been defaulted, and explain the status. 9. Are any related claims or actions pending or anticipated? Yes ........................ 11. 10. Identify and describe the related matter(s) No ........................ Nature of the case (check all that apply): PI -Vehicle................... Employment -Termination ............... Real Property .............. Breach of Contract ..... PI - Slip & Fall .............. Employment .............. -Discrimination Residential Lease ........ Collection-Consumer... PI - Premises ............... Housing Discrimination .. Commercial Lease........ Collection-Commercial. PI - Product Liability ....... Police Misconduct ........ Construction Defect ...... Fraud PI - Other .................... Other Civil Rights ......... Insurance - Bad Faith .... Business Tort ........... Medical Malpractice ....... Legal Malpractice ......... Insurance - Subrogation Intellectual Property.... Wrongful Death ............ Other Malpractice ......... Securities .................. (EMSC Statement-Rev3) Other ..................... ..................... 2001 © American LegalNet, Inc. 12. Relief requested by party filing Statement Please specify the amount of damages claimed Compensatory damages ................................... Punitive damages ............................................ 13. General damages 14. Medical expenses (past & estimated future) 15. Loss of earnings (past & estimated future) 16. Other special damages Specific performance ........................................ Declaratory relief .............................................. Injunction ........................................................ Accounting ...................................................... Other equitable relief ........................................ No affirmative relief requested ........................... Mediation Assessment Factors 17. Do you believe this case is exempt from the Mandatory Early Mediation Pilot Program pursuant to California Rules of Court, Rule 1640.1? Yes ........................ 18. No ........................ Do you believe this case is exempt from referral to mandatory early mediation pursuant to California Rules of Court, Rule 1640.2? Yes ........................ No ........................ 19. If you believe the case is exempt from the Pilot Program or from referral to mandatory early mediation, state the basis of the exemption. 20. Does the party filing Statement request this case be referred to mediation under the Pilot Program? Yes ........................ 21. No ........................ Does the party filing Statement oppose case being referred to mediation under the Pilot Program? Yes ........................ No ........................ 22. Indicate why you do or do not think this case is appropriate for mediation. An attachment maybe used if necessary. 23. How long after the Early Mediation Status Conference do you think this case will be ready for meaningful mediation? more than 30 days .... 60 days .... 90 days .... 120 days .. 150 days .. 150 days .. 24. What discovery and law and motion has been conducted in this case? Depositions Interrogatories Productions or inspections Physical or mental exams Requests for admission Motion(s) for (specify): Other (specify): 25. What additional discovery or law and motion do you think is necessary before this case will be ready for meaningful mediation? Depositions of: Interrogatories to Production or inspection of: Physical or mental exams Requests for admission Motion(s) for (specify): Other (specify): 26. List three nominees to serve as mediator in this case, regardless of whether you consent to or oppose referral to mediation. The names and profiles of the Court's Pilot Program Panel mediators are available in the ADR Office and on its website. 27. The parties may select a mediator not on the court's Pilot Program Panel if authorized at the Early Mediation Status Conference and the parties agree to pay the non-panel mediator's compensation. (Non-panel mediators may request compensation from the court, which requests will be considered on a case by case basis.) Are you requesting approval of a mediator who is not on the Pilot Program panel and do you agree to pay his or her fee? Yes .................................................................... No ..................................................................... 2001 © American LegalNet, Inc.