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Completing a
Request for Mediation

You have two options to complete the Request for Mediation form: Complete the form and submit electronically or print and sign the completed form before sending via mail or email. If you have questions, please contact us by email or phone: 1-888-298-3857 for assistance. 

2. Print and fill out manually.

If you would like to print out a Request for Mediation Form and complete it manually before sending, Click Here, and follow the steps below.

​1. Open the form PDF by clicking the link above

2. Print the form
3. Fill out the form
4. Sign the form
5. Save a copy for your files
6. Mail, or scan and email, the SIGNED form to the address noted at the top of the form​

Typing on the Computer

1. Complete the form electronically.

If you would like to fill out the Request for Mediation Form electronically, Click Here, and follow the steps below.

1. Open the electronic form by clicking the link above

2. Click the "Start Filling" button on the form

3. Fill out the form by typing in the form field boxes 
4. Sign the form electronically

5. Click the Submit button on the electronic form
6. You will receive verification that the form has been submitted.

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