Case Submission

Case Caption : vs
Plaintiff / Claimant
Name:
Attorney/Representative:
Law Firm:
Address:
City, State, Zip:		, ,
Telephone:
Fax:
E-mail Address:
File Number:

Defendant / Respondant
Name:
Attorney/Representative:
Law Firm:
Address:
City, State, Zip:		, ,
Telephone:
Fax:
E-mail Address:
File Number:

Insurance Carrier
Name:
Name of Insured:
Claims Representative:
Address:
City, State, Zip:		, ,
Telephone:
Fax:
E-mail Address:
Claim Number:

Type of ADR Process Requested:

Type of Dispute:

Estimated Hearing Time:

Name of the Neutral or Neutrals You Wish to Consider:

Location Requested:

Additional Information:

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