The Filing Party IsClaim RepresentativePlaintiff AttorneyDefense AttorneyLegal Assistant

Insured

Claim #

Claim Representative

Insurance Company

Street Address

City

StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip Code

Phone Number

Fax Number

Email Address

Defense Attorney

Defense Attorney Email

Legal Assistant

Legal Assistant Email

Firm

File #

Street Address

City

StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip Code

Phone Number

Fax Number

Claimant(s)

Attorney

Firm

File #

Street Address

City

StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip Code

Phone Number

Fax Number

Email Address

Will a Structured Settlement Broker be attending? If yes, please list in "Other Parties" sectionNoYes

Select TypePlaintiffDefendantSturcture Broker

Insured / Claimant

Representative / Attorney / Broker

Insurance Company / Firm

Claim / File #

Street Address

City

StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip Code

Phone Number

Fax Number

Email Address

Select TypePlaintiffDefendantStructure Broker

Insured / Claimant

Representative / Attorney / Broker

Insurance Company / Firm

Claim / File #

Street Address

City

StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip Code

Phone Number

Fax Number

Email Address

Date of Loss

In SuitYesNo

Last Offer

Last Demand

Type of Dispute

Issues: LiabilityYesNo

Issues: DamagesYesNo

Procedure RequestedMediationTelemediationHigh-Low ArbitrationArbitrationPaper ArbitrationMed-ArbPrivate Jury TrialJudicial RefereeApellate InsightEvaluation RoundtableInteractive SurveyClass Actions

Court Case Number

Court Venue

Have all Parties Agreed to this Procedure?NoYes

Special Instructions