Superior-25 (revised July 2018) STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS SUPERIOR COURT 2018 MEDIATION SUBMISSION FORM SETTLEMENT WEEK - DECEMBER 10, 11, and 12, 2018 at the LICHT JUDICIAL COMPLEX Providence/Bristol County Kent County Washington County Newport County Plaintiff(s) (Name each plaintiff individually) Civil Action Number Defendant(s) (Name each plaintiff individually) Third Party Defendant(s) (Name each individually) THIS FORM MUST BE SUBMITTED TO THE ARBITRATION OFFICE BY OCTOBER 31, 2018 A ONE-PAGE CASE SUMMARY MUST BE SUBMITTED TO THE SUPERIOR COURT ARBITRATION OFFICE BY EACH PARTY PRIOR TO NOVEMBER 9, 2018. Please answer the following questions regarding your case: Is this case assigned to the trial calendar? Yes No Does the case contain any claim for declaratory judgment or equitable relief? Yes No Have appearances been entered for all parties? Yes No Is there a lien holder? Yes No Is there an insurer involved? Yes No If Yes, Insurance Company Name, Address, and Telephone: Please check the appropriate case type: Book Account Landlord/Tenant Personal Injury Tax Appeal Commercial Malpractice, Accounting Police Brutality Theft and Loss Contract Malpractice, Legal Products Liability Wills and Trusts Discrimination Malpractice, Medical Property Wrongful Arrest Dog Bite Motor Vehicle/Personal Injury Slip and Fall Other I certify that I agree to mediation and that discovery has sufficiently concluded so that a meaningful mediation session may occur. (Signature) (Signature) Rhode Island Bar Number: Rhode Island Bar Number: Law Firm: Law Firm: Address: Address: Telephone: Telephone: Facsimile: Facsimile: EVERY ATTORNEY INVOLVED IN THIS CASE MUST PERSONALLY SIGN THIS FORM. ATTACH ADDITIONAL FORMS IF NECESSARY. American LegalNet, Inc. www.FormsWorkFlow.com