Case Submission Form

Please fill out the form below to the best of your ability and someone will contact you shortly.

Case Submission

Submitted by:

Plaintiff Attorney

Defense Counsel

Insurance Claim Rep.

Hearing

For Arbitrations

Have all parties agreed to proceed with ADR?

Parameters (To be negotiated by the parties; not to be discussed with Hearing Officer)

Low

High

Plaintiff Information

Name of Plaintiff

Plaintiff Attorney Information

First Name

Last Name

Law Firm

Email Address

Phone

(###)

###

####

Defendant Information

Name of Defendant

Defense Counsel Information

First Name

Last Name

Law Firm

Phone

(###)

###

####

Name of Insurance Carrier

Claim Number

Claim Rep.

First Name

Last Name

Claim Rep. Email Address

Phone

(###)

###

####

Date of Loss

YYYY

CO-Defendant Information

(If Applicable) Name of Co-Defendant

Co-Defense Counsel Information

First Name

Last Name

Law Firm

Phone

(###)

###

####

Claim Number

Claim Rep

First Name

Last Name

Phone

(###)

###

####

Requested Arbitrator/Mediator

Notes:

May include any additional information pertinent to the case such as, "Pending a Film Review," "Awaiting Discovery" or "Not in suit."