Fillable Division of Consumer Services Alternative Dispute Resolution Unit (Florida Department of Financial Services)

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Division of Consumer Services Alternative Dispute Resolution Unit (Florida Department of Financial Services)

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DEPARTMENT OF FINANCIAL SERVICES
Division of Consumer Services – Alternative Dispute Resolution Unit
INSURANCE MEDIATION DISPOSITION FORM
For Automobile, Personal Residential or Commercial Residential Insurance Mediations
Insurance
Company:
Insured Name:
Claim Number: DFS File Number:
Mediation Conference Information
Conference Date:
Time:
Address:
Mediator Name:
Name of Party Requesting Mediation:
Resolution of Mediation (Please select one of the following)
Settled in Mediation Impasse
Settled Prior to Mediation
Insured Did Not Attend Mediation Company Representative Did Not Attend Mediation
Mediation Request Withdrawn by Insured
Mediation Request Withdrawn by Company
Key Agreements (Note: If commercial residential mediation, include hours worked):
Complete this form and return it to: DEPARTMENT OF FINANCIAL SERVICES
Division of Consumer Services
Alternative Dispute Resolution Unit
200 E. Gaines Street
Tallahassee, Florida 32399-4212
Mediation@MyFloridaCFO.com
Fax 850-488-6372
DFS-I4-2169
Rev. 02/16
69J-176.022, 69J-166.002, 69J-166.031
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Division of Consumer Services Alternative Dispute Resolution Unit (Florida Department of Financial Services)

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Completed 20 November 2020

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