County Court Mediation Scheme Claimant Form

County Court Mediation Scheme

Claimant Application Form
The CEDR County Court Mediation Scheme provides an opportunity for parties to resolve disputes through dialogue facilitated by a professional CEDR-Accredited Mediator. This Scheme is available to users who have been referred by a Court, and consent to using a Mediator to resolve the dispute that has arisen.

The Centre for Effective Dispute Resolution (CEDR Services Ltd) is a Not-for-Profit organisation approved to provide dispute resolution services. CEDR will mediate disputes that are eligible.

CEDR is not responsible for paying compensation or making a financial award. If your dispute is resolved via the mediation process and a payment has been agreed, then this is sorted out between the parties. However, both parties are equally responsible for paying CEDR’s fees.

How do I make a complaint and what happens next?
- Upon receipt of your completed form CEDR will acknowledge receipt within 3 working days
- Full details of the mediation procedure and guidance is available on the CEDR website
- If you require additional guidance or assistance, please contact the CEDR office via email at
I understand there is a standard fee of £450 + VAT per party, payable to CEDR Services Ltd.

Application Form

Please answer all sections on this form to the best of your knowledge as any missing information may cause delays with the process.
1. About you (Party A - Claimant)

Please provide your full contact details.
Name of Party
Contact Person Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Telephone

Area CodePhone Number
Please select the County Court that has referred you to CEDR:*
2. Representation
YesNo
If someone is applying on your behalf, please provide their details here and sign the declaration.
Name

First NameLast Name
Organisation
If applicable
Email
example@example.com
Telephone

Area CodePhone Number
To be signed by the applicant named in section 1. I hereby give my authority for the above named person to represent me:

Clear
Date

DayMonthYear

3. Party B Details (Respondent)

Please give the full trading name of the Business that you are in dispute with.
Company name*
Contact name*

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
2. Representation
YesNo
Please provide the respresentation details below.
Contact name

First NameLast Name
Company name
Phone Number

Area CodePhone Number
Email
example@example.com
4. Dispute details
This scheme is only suitable for cases where the total value of the claim ranges from £10,001 to 100,000.
Please confirm the total value of the claim in the box below.*
Between £10,001 - £100,000
Select the Dispute Type
4.1 Please provide a brief summary of the dispute.
Please confirm which dates you are available for mediation. Please choose 3 dates. The other party will then be able to select one of thee dates.
Date 1

DayMonthYear
Date 2

DayMonthYear
Date 3

DayMonthYear

5. Declarations

Please read the following statements carefully and make sure that you understand your responsibilities before signing this application form.
- I/We believe that the facts stated in this application and claim form are true and my claim does not sit outside of the range £10,001 - £100,000 + VAT.
- I/We agree and understand that the mediator’s recommendations are not binding unless written down and signed by both parties in the agreement.
- I/We also understand that mediation is a confidential process in which the Mediator as a neutral third party, assists parties in working towards a negotiated agreement, with the parties in ultimate control of decision to settle and the terms of resolution.
- I/We declare that I/we am/are authorised to sign this form and understand that it is my/our responsibility to ensure that I/we understand the process and will seek guidance from CEDR if required.
- I/We understand that a copy of this form will be given to the Respondent.
- I/We understand that any other information given to the Mediator during the Mediation will be confidential unless I/We permit the Mediator to give information to the other party.
- I/We accept that the proceedings are confidential and without prejudice.
- I/We understand that the Mediator does not give legal advice.
- I/We also understand the Mediator does not act as a judge or arbitrator. However, should the parties be unable to reach an agreement between them, the Mediator may recommend a solution to the dispute.
- I/We believe that the facts stated in this claim form are true.
Signature*

Clear
Type your name*

First NameLast Name
Date*

DayMonthYear

6. Payment

County Court Mediation Scheme Payment*

County Court Mediation Scheme Application Fee

The application fee is £450 + VAT, per party

£450.00

Subtotal

£0.00

Tax

£0.00

Total

£0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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County Court Mediation Scheme

How do I make a complaint and what happens next?

Application Form

1. About you (Party A - Claimant)

2. Representation

3. Party B Details (Respondent)

2. Representation

4. Dispute details

5. Declarations

6. Payment