ADR Case Referral Intake ADR039 - Superior Court of California ...
ADR Case Referral Intake ADR039 - Superior Court of California ...
ADR Case Referral Intake ADR039 - Superior Court of California ...
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<strong>Superior</strong> <strong>Court</strong> <strong>of</strong> <strong>California</strong>, County <strong>of</strong> Los AngelesJOHN A. CLARKE, EXECUTIVE OFFICER/CLERK<strong>ADR</strong> CASE REFERRAL INTAKEALTERNATIVE DISPUTE RESOLUTION (<strong>ADR</strong>)(Please type or print clearly)CASE INFORMATION<strong>Case</strong> Number: <strong>Court</strong>house: Dept.:<strong>Case</strong> Name:Litigation Type: Civil Family Law Probate Other (specify): _________________________________________________<strong>ADR</strong> Process: MEDIATION ARBITRATION NEUTRAL EVALUATION SETTLEMENT CONFERENCE<strong>Case</strong> Type: See Page 2<strong>ADR</strong> Completion Date:Amount in Dispute:Plaintiff/Petitioner or attorney: $0-$25,000 $50,000-$100,000 $250,000-$500,000 $750,000-$1,000,000$25,000-$50,000 $100,000-$250,000 $500,000-$750,000 Over $1,000,000- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Defendant/Respondent or attorney: $0-$25,000 $50,000-$100,000 $250,000-$500,000 $750,000-$1,000,000$25,000-$50,000 $100,000-$250,000 $500,000-$750,000 Over $1,000,000NEUTRAL SELECTIONParty Select Panel:The parties select the following Neutrals in order <strong>of</strong> preference from the <strong>Court</strong> <strong>ADR</strong> Party Pay Panel and acknowledge they are undertaking afinancial commitment in selecting a Party Pay Panel Neutral.1) NAME: ___________________________________________________________ NEUTRAL NO.: ____________________________2) NAME: ___________________________________________________________ NEUTRAL NO.: _________________________________________________________________________________________(signature <strong>of</strong> plaintiff/petitioner or attorney)ADDITIONAL SIGNATURES LISTED ON ATTACHED PAGE_____________________________________________________________(signature <strong>of</strong> defendant/respondent or attorney)Random Select Panel:The parties understand that a Neutral from the <strong>Court</strong> <strong>ADR</strong> Pro Bono Panel will be assigned on a random basis (civil mediation and arbitration only).NAME OF ASSIGNED NEUTRAL: ___________________________________________________________NEUTRAL NO.: ____________________________PARTIESATTORNEY NAME:FIRM:ADDRESS:ATTORNEY NAME:FIRM:ADDRESS:CITY: STATE: ZIP: CITY: STATE: ZIP:PHONE: ( ) FAX: ( ) PHONE: ( ) FAX: ( )E-MAIL:ATTORNEY FOR:___________________________________________________________________(party name)(party type)ATTORNEY NAME:FIRM:ADDRESS:E-MAIL:ATTORNEY FOR:____________________________________________________________________(party name)(party type)ATTORNEY NAME:FIRM:ADDRESS:CITY: STATE: ZIP: CITY: STATE: ZIP:PHONE: ( ) FAX: ( ) PHONE: ( ) FAX: ( )E-MAIL:E-MAIL:ATTORNEY FOR:ATTORNEY FOR:___________________________________________________________________ ____________________________________________________________________(party name)(party type)(party name)(party type)ADDITIONAL PARTIES LISTED ON PAGE THREEFOR OFFICE USE ONLYReceived by: ________________________________ ___________________________NameDateLA<strong>ADR</strong> 039 (Rev. 04/09)LASC Approval 10-04<strong>Case</strong> Mgr Assigned: ________________________________ _____________________NameDatePage 1 <strong>of</strong> 3
<strong>ADR</strong> CASE REFERRAL INTAKE(continued)<strong>Case</strong> Name:<strong>Case</strong> Number:CASE SELECTION CRITERIACASE TYPEAntitrust/Trade RegulationAuto Tort - Personal Injury/Property Damage/Wrongful Death (PI/PD/WD)Auto Tort - Uninsured Motorist - PI/PD/WDCivil HarassmentConstruction DefectContract - Breach <strong>of</strong> Rental/Lease Contract (not insurance, UD, or wrongful eviction)Contract - CollectionsContract - Contract/Warranty Breach - Seller Plaintiff (not insurance, fraud, or negligence)Contract - Contractual FraudContract - Insurance Coverage/SubrogationContract - Negligent Breach <strong>of</strong> Contract/Warranty (not insurance or fraud)Contract - Other Breach <strong>of</strong> Contract/Warranty (not insurance, fraud, or negligence)Contract - Tortious InterferenceDeclaratory Relief OnlyElder/Dependent Adult AbuseEmployment - Labor Commissioner AppealsEmployment - Other (not wrongful termination or labor commissioner appeal)Employment - Wrongful TerminationFamilyInjunctive Relief Only (not domestic/harassment)Non-PI/PD/WD Tort - Business/Commercial Tort (not fraud or breach <strong>of</strong> contract)Non-PI/PD/WD Tort - Civil Rights (e.g., discrimination, false arrest)Non-PI/PD/WD Tort - Defamation (e.g., slander, libel)Non-PI/PD/WD Tort - Fraud (no contract)Non-PI/PD/WD Tort - Intellectual PropertyNon-PI/PD/WD Tort - Legal MalpracticeOther PI/PD/WD Tort - AsbestosOther PI/PD/WD Tort - Intentional (e.g., assault, vandalism, etc.)Other PI/PD/WD Tort - Intentional Infliction <strong>of</strong> Emotional DistressOther PI/PD/WD Tort - Medical MalpracticeOther PI/PD/WD Tort - Premises LiabilityOther PI/PD/WD Tort - Product Liability (not asbestos, toxic/environmental)Partnership & Corporate GovernanceProbateReal Property - Eminent Domain/CondemnationReal Property - Mortgage ForeclosureReal Property - Quiet TitleReal Property - Wrongful EvictionReal Property - OtherSecuritiesToxic Tort/EnvironmentalWorkplace HarassmentWrit <strong>of</strong> MandateDo you need a neutral who accepts cases on short notice? Yes NoJurisdiction Type: Unlimited LimitedLanguage ability needed other than English:LA<strong>ADR</strong> 039 (Rev. 04/09)LASC Approval 10-04ADA AccommodationsAccessible parkingAccessible elevatorsAccessible public phonesAccessible tables/countersLocation: Zip Code:Accessible entranceAccessible restroomsAccessible listening devicesOther (specify):City:Page 2 <strong>of</strong> 3
(This Form Must Be Completed In Detail)<strong>Case</strong> Name:<strong>ADR</strong> CASE REFERRAL INTAKE(continued)<strong>Case</strong> Number:ATTORNEY NAME:FIRM:ADDRESS:ADDITIONAL PARTIESATTORNEY NAME:FIRM:ADDRESS:CITY: STATE: ZIP: CITY: STATE: ZIP:PHONE: ( ) FAX: ( ) PHONE: ( ) FAX: ( )E-MAIL:ATTORNEY FOR:___________________________________________________________________(party name)(party type)ATTORNEY NAME:FIRM:ADDRESS:E-MAIL:ATTORNEY FOR:___________________________________________________________________(party name)(party type)ATTORNEY NAME:FIRM:ADDRESS:CITY: STATE: ZIP: CITY: STATE: ZIP:PHONE: ( ) FAX: ( ) PHONE: ( ) FAX: ( )E-MAIL:ATTORNEY FOR:___________________________________________________________________(party name)(party type)ATTORNEY NAME:FIRM:ADDRESS:E-MAIL:ATTORNEY FOR:___________________________________________________________________(party name)(party type)ATTORNEY NAME:FIRM:ADDRESS:CITY: STATE: ZIP: CITY: STATE: ZIP:PHONE: ( ) FAX: ( ) PHONE: ( ) FAX: ( )E-MAIL:ATTORNEY FOR:___________________________________________________________________(party name)(party type)ATTORNEY NAME:FIRM:ADDRESS:E-MAIL:ATTORNEY FOR:___________________________________________________________________(party name)(party type)ATTORNEY NAME:FIRM:ADDRESS:CITY: STATE: ZIP: CITY: STATE: ZIP:PHONE: ( ) FAX: ( ) PHONE: ( ) FAX: ( )E-MAIL:ATTORNEY FOR:___________________________________________________________________(party name)(party type)E-MAIL:ATTORNEY FOR:___________________________________________________________________(party name)(party type)To obtain additional case information, visit <strong>Case</strong> Summaries at www.lasuperiorcourt.orgLA<strong>ADR</strong> 039 (Rev. 04/09)LASC Approval 10-04Page 3 <strong>of</strong> 3
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