Debt Mediation Claim Form
To begin we need some details about your claim
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This is just so we know which track it needs to follow, any value case is applicable under this scheme up to £10,000

First we need your details

Now we need the other parties details

You will enter the values claimed next so don't worry about these for now
These don't need to be precise but they are helpful in allowing us to understand what order events happened in
This should include the money owed to you, prior to any incurred legal, court, or mediation costs
Whilst difficult to claim, these are none the less important for us to be aware of. These may include loss of earnings etc
This might include bank statements, emails to the other party, proof of losses etc
Please note this is never disclosed to the other party! this is for the mediators use only so that an offer is not wrongfully rejected. Entering a figure higher than that which you would genuinely accept will not assist the process as it will not be used in negotiation, however, it might prevent settlement being reached


This agreement related to the provision of the service referred to as ‘small claims mediation’ on the Companies website. For the purpose of this agreement the following terms apply;

The Company Northern Independent Mediation trading as National Dispute Resolution and based at Refuge Buildings, Sunbridge Rd, Bradford, Yorkshire, BD1 2AZ

The Parties The parties involved in the claim as outlined on the case summary form. These include both the person/company requesting the mediation and any opposing party named on the summary form

The Mediation The service provided under this contract from the making of the request to mediate online until the completion of the service including the signing of an agreement or the issuance of a mediation certificate


1.1. The Mediation shall be held and conducted according to this Agreement to Mediate.
1.2. Parties will conduct the Mediation personally or in the case of businesses, corporations or other legal entities, through their authorised representatives. An authorised representative must have full authority of the represented Party to negotiate, compromise and settle the Dispute on its behalf. Any restriction on this authority is to be raised with the Company prior to the mediation commencing.
1.3. Any settlement reached in the Mediation will not be legally binding until it has been reduced to writing and signed by, or on behalf of, each of the Parties (“Settlement Agreement”).

2.1. The Mediation will be conducted online, by telephone or other method of communicating over distance.
2.2. The Mediation shall be deemed to continue until any one of the following occurs:
2.2.1. when a written Settlement Agreement is executed and signed by the Parties; or
2.2.2. a written notice of withdrawal is given by any Party; or
2.2.3. the time set for the Mediation has expired without agreement for continuation or resumption; or
2.2.4. the Mediator decides, at his/her absolute discretion, and notifies the Parties, that continuing the Mediation is unlikely to result in a settlement or is otherwise undesirable or inappropriate for any reason; or
2.2.5. the Mediator decides that he/she should retire for any reason
2.3. The date of commencement shall be the date of the submission of the mediation request online and the period for mediation shall be a maximum of 2 hour of mediation. No additional costs will be incurred by NDR and no party shall be charged for extra time unless they agree to this in writing

3.1. The fee for mediation is that paid at the time of submission of the form and as outlined on the Ministry of Justices online mediation directory. This fee is dependent on the claim value not exceeding £2000, where the fee does exceed this amount the company reserves the right to charge an uplift fee in line with that stated on the Online Directory or the companies website, whichever is the lesser amount.
3.2. Where a party is represented at the Mediation by a legal representative, that legal representative is liable for their client’s share of the costs of the Mediation in the same way as they are liable for disbursements incurred in any litigation.
3.3. Each party will pay its own costs and expenses in instructing any legal representative to prepare for and/or participate in, the Mediation. Unless agreed otherwise, these costs and expenses will be costs in the case.

4.1. A Party does not require legal representation to attend Mediation.
4.2. Where a Party is not legally represented, they are advised to obtain independent legal advice before, during and after the Mediation and prior to finalising any agreement reached pursuant to the Mediation.
4.3. The Parties recognise that the Mediator will not offer legal advice nor act as a legal advisor for any Party nor will they provide any Party with a legal analysis with respect to a Party's legal position or rights.
5.1. The company shall issue to the parties that took part in mediation a ‘mediation certificate’ this certificate shall state;
5.1.1. Which parties agreed to undertake mediation
5.1.2. That mediation did or did not take place as relevant
5.1.3. Where mediation was refused the reasons for that refusal
5.1.4. The fee incurred in seeking to undertake mediation
5.1.5. If relevant that mediation took place but did not result in full agreement
5.2. Where a certificate is issued the cost will be covered by the fee paid when submitting the case for mediation. This fee shall cover all administrative costs in seeking to arrange mediation and in the issuance of this certificate.

6.1. The Mediator may hold private sessions with each Party and/or their representatives. These private sessions are designed to improve the Mediator’s understanding of the Party’s position and to facilitate the Mediator in expressing each Party’s view point to the other side.
6.2. Information received by the Mediator through such sessions shall be and shall remain confidential save that (a) it is in any event publicly available or (b) the Mediator is specifically authorised by that Party to disclose it to the other Party. This clause is subject to Clause 6.

7.1. Everyone involved in any manner in the Mediation undertakes to each other that, unless otherwise agreed to in writing by the Parties or their respective advisers, they shall maintain and respect the confidentiality of any and all information of any nature made or produced for, or arising in connection with, the Mediation, save:
7.1.1. as may be required by law, in particular relating to disclosed or proposed criminal activity, whether under the Proceeds of Crime Act 2002 and/or any other regulations relating thereto or otherwise to report to the National Crime Intelligence Service any knowledge or suspicion relating to the involvement of the proceeds of crime (including tax evasion) and is precluded by law from informing the Parties of his/her intention to do so; and/or
7.1.2. insofar as any Party needs to disclose any such information in order to comply with any statutory obligation or obtain professional advice;
7.1.3. where the Mediator believes that information should be passed on for welfare reasons or other reasons that the Mediator deems fit; and/or
7.1.4. as may be necessary to implement and/or enforce any settlement agreement.
7.2. Everyone involved in the Mediation also agrees to keep confidential and regard as privileged and shall not use what happened or what was said at the Mediation and/or the terms of any settlement (unless the settlement agreement has its own confidentiality terms in which case those terms shall prevail).
7.3. Everyone involved in the Mediation also recognises that the Mediation is for the purpose of attempting to achieve a negotiated settlement and as such all documents, correspondence, information or other material (in any format) and/or matters of any nature made or produced for, or arising in connection with, the Mediation is without prejudice and will be inadmissible in any litigation or arbitration of the Dispute.
7.4. Evidence which is otherwise admissible shall not be rendered inadmissible as a result of its use in the Mediation.
7.5. The Parties, their advisers or representatives will not take steps in any jurisdiction to require or compel the Mediator or any other person attending the Mediation to act as a witness in any proceedings connected in any way with the Mediation or the subject matter of the Dispute, or to testify or produce records, notes or any other information or material whatsoever in any future or continuing proceedings, unless such documents or information would have been admissible or discloseable in any event.
7.6. Every person involved in the Mediation will keep confidential and not use for any collateral or ulterior purpose the fact that the Mediation is to take place or has taken place, other than to inform a court dealing with any litigation relating to the dispute of that fact.
7.7. Where the Mediation has taken place as a result of a Court order, the Parties agree that the Court can be notified of the fact that the case has resolved through mediation and if not resolved that a mediation has taken place. The notification will come from the parties and take the form of a letter agreed between the parties at the conclusion of the Mediation. The notification will not disclose the terms of any settlement, unless otherwise agreed by the Parties.
7.8. All documents, statements, information and other material produced prior to or during the course of the mediation, save to the extent those documents disclosed already and in the domain of the litigation, whether in writing or orally, shall be held in confidence by the Parties and shall be used solely for the purposes of the Mediation.

8.1. The Mediator shall not be liable to the Parties or anyone involved in the Mediation for any act or omission in connection with the services provided by them, or in relation to, the Mediation, unless the act or omission is shown to be fraudulent or in bad faith. This exclusion clause applies subject to any applicable law

9.1. The referral of this dispute to Mediation does not affect the rights that may exist under Article 6 of the European Convention on Human Rights. If the dispute is not settled by mediation, the Parties’ right to a fair trial remain unaffected.
9.2. This Mediation Agreement shall be governed by, construed and take effect in accordance with English Law.

10.1. This Agreement to Mediate is to be signed electronically on submission of the request to mediate.
10.2. The parties agree that this signature is valid and executed with the intention to form a legally binding contract.
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