Date:
(Claimant/Plaintiff)		v. (Insured/Defendant)
Case Submitted by		for Claimant/Plaintiff Insured/Defendant Other
		If "Other," describe:
Case Submitted for	Mediation Binding Arbitration Court Ordered Other	If "Other," describe:

Claim/File No.:
Court:
Docket or Trial Date:
Judge:
Insurer/Company Name:
Adjuster:
Title:
Street:
City:
State:
Zip:	-
Phone Number:	() -
Fax Number:	() -
Insurance Claim Number:
Fees to be paid by:	Divided Equally Submitting Party Insured/Defendant Other
If divided, among whom?	1. 2. 3. 4. 5. 6. 7. 8.
Plaintiff Counsel
Representing (Name of Party):
Attorney:
Law Firm Name:
Street:
City:
State:
Zip:	-
Phone Number:	() -
Fax Number:	() -
E-mail Address:
Defense Counsel
Representing (Name of Party):
Attorney:
Law Firm Name:
Address:
City:
State:
Zip:	-
Phone Number:	() -
Fax Number:	() -
E-mail Address:
Additional Parties:	Yes No
For additional parties, please fill out our Case Submission Form: Additional Parties page.

Case Type:	Automobile Commercial Construction Domestic Relations Employment Homeowner Medical Malpractice Personal Injury Premises Liability Products Liability Workers' Comp Other
If "Other", please describe:
Brief description of case:
Date of injury/loss/etc.:	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 1991 1992 1993 1994 1995 1996 1997
Are there any trial dates or time limitations?
Do you have sufficient information to settle this case?
If not, what is needed?
Have you discussed alternative dispute resolution with the other side?	Yes No
Result?

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