MACOMB CIRCUIT COURT CASE EVALUATOR APPLICATION (Not to be used by ADR Mediator Applicants) ! New application ! Renewal Application P# Name Firm name or Business address Street City State and Zip Telephone: 1. ( ) Fax ( ) Panel sought (select one): ! General Civil ! Personal Injury ! Neutral (! Plaintiff ! No. ! Defense) 2. Have you served as a case evaluator? ! Yes attachment. 3. When were you admitted to the practice of law (month/day/year)? 4. Are you a member in good standing of the State Bar of Michigan? 5. Do you qualify for service in this jurisdiction by (a) ! residing in Macomb County (b) ! maintaining an office in Macomb County, or (c) ! an active practice in Macomb County? 6. Please provide factual support for your qualification(s) under question 5 by providing your Macomb County address (if different than your business address above) or a description of your “active practice” on an attachment. 7. Please demonstrate that a substantial portion of your practice for the last 5 years has been devoted to civil litigation matters as required by MCR 2.404(B)(2)(c) on an attachment. If yes, please describe on an ! Yes ! No If you are applying for service on the Personal Injury List pursuant to MCR 2.404(B)(4), please answer the following questions. All others skip to the certification section. 1 (10/6/04) American LegalNet, Inc. www.FormsWorkflow.com 1. In your practice, do you primarily represent: ! Plaintiffs? ! ! Defendants? Not identifiable? 2. Please demonstrate that you have had an active practice in personal injury for at lest the last 3 years as required by MCR 2.404(B)(2)(d) on an attachment. 3. How many cases on average have you handled during MCR 2.403 case evaluation as counsel for a party over the last three years? . 4. How many cases on average have you arbitrated as counsel for a party over the last three years? . 5. How many cases on average have you participated in facilitation or mediation as counsel for a party over the last three years? . 6. How many days of the year have you acted as a case evaluator under MCR 2.403 over the past three years, in personal injury cases? . 7. How many days of the year have you acted as an arbitrator over the past three years, in personal injury cases? . 8. How many days of the year have you acted as a facilitator over the past three years, in personal injury cases? . 9. How many personal injury cases did you resolve by way of settlement over the past three years on an annual basis? . 10. How many personal injury cases did you try to a verdict in the past three years? . 11. Within your practice, what percentage of your cases are: A. Personal injury? C. Professional malpractice? % % B. Products Liability? % D. Employment? % CASE EVALUATOR ELIGIBILITY CERTIFICATION I certify, pursuant to MCR 2.404(B)(1), that I meet the requirements for service under the Macomb County Circuit Court’s selection plan and that I will not discriminate against parties, attorneys, or other case evaluators on the basis of race, ethnic origin, gender, or other protected personal characteristic. Date Signature 2 (10/6/04) American LegalNet, Inc. www.FormsWorkflow.com GENDER/RACE/ETHNICITY INFORMATION - OPTIONAL In order to evaluate our efforts to provide bias free case evaluators and diversity, we ask you to voluntarily identify your gender/race/ethnicity. This information will be maintained separately from the other pages of the application. P Name (First, Middle initial, last. Print or write legibly) Bar No. Please check the appropriate box: Gender ! Male ! Female Race/Ethnicity ! American Indian or Alaskan Native ! Asian or Pacific Islander ! Black/African American (non-Hispanic) ! Caucasian (non-Hispanic) ! Hispanic ! Other Please specify Return this application to: Macomb Circuit Court Case Evaluation Clerk 40 N. Main, 5th Floor Mt. Clemens, MI 48043 3 (10/6/04) American LegalNet, Inc. www.FormsWorkflow.com