* = Mandatory Fields

Index #*

Case Caption*

Submitted By*
PlaintiffDefense
Attorney Name*

Phone*

Email*

Please check one*

Accident / Incident Date

ADR Method
MediationArbitration

Parameters
SuggestedAgreed Upon
High

Low


Claim#

Insurance Company

Adjuster

Phone

Email

Additional Carrier?

Claim#

Insurance Company

Adjuster

Phone

Email

Additional Carrier?

Claim#

Insurance Company

Adjuster

Phone

Email

Additional Carrier?

Claim#

Insurance Company

Adjuster

Phone

Email

Additional Carrier?

Claim#

Insurance Company

Adjuster

Phone

Email

Additional Comments?

Call Upon Receipt?
Yes