Please Select who you are to continue with case submission
I am a:
Plaintiff's Attorney
Defense Attorney
Claim Representative
Handling Attorney:
Name:
Examiner Name:
Firm Name:
Law Office:
Insurance Company:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Suit Filed?
Yes
No
Caption:
(full name plaintiff)
Vs:
(full name defendant)
Claim #:
Date of loss:
Please check one:
Auto
Slip & Fall
Other (specify)
Insurance Carrier -or- Defense Firm:
Plaintiff's Firm
Plaintiff's Firm
Address:
City:
State:
Zip:
Phone:
Fax:
Claim Rep -or- Defense Attorney:
Handling Attorney
Handling Attorney
Email:
Please check one:
Mediation
Either
Arbitration
Damages & Liability:
Damages Only:
Suggested Arbitration Parameters (If Applicable)
Hi:
Low:
Liability:
Clear
At Issue
Are all necessary documents ready or available?
Yes
No
(if no) Need:
Contact Defense Counsel?
Yes
No
Please fill out:
Name
Law Office:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Have all necessary parties agreed to this process?
Yes
No
Coments:
Are additional parties needed for this hearing?
Yes
No (If yes, complete below)
Coments:
Co-Plaintiff
Co-Defendant
Name:
Carrier/Atty:
Claim#:
Rep. Name:
Address:
City:
state:
Zip:
Phone#:
Fax#:
Co-Plaintiff
Co-Defendant
Name:
Carrier/Atty:
Claim#:
Rep. Name:
Address:
City:
state:
Zip:
Phone#:
Fax#:
Co-Plaintiff
Co-Defendant
Name:
Carrier/Atty:
Claim#:
Rep. Name:
Address:
City:
state:
Zip:
Phone#:
Fax#:
Co-Plaintiff
Co-Defendant
Name:
Carrier/Atty:
Claim#:
Rep. Name:
Address:
City:
state:
Zip:
Phone#:
Fax#: