| The Filing Party is |
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| Defendant |
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| Insured |
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| Claim # |
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| Claim Representative |
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| Insurance Company |
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| Street Address |
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| City |
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| State |
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Zip Code |
| Phone |
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| Fax |
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| Email Address |
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| Defense Attorney |
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| Defense Attorney Email |
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| Legal Assistant |
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| Legal Assistant Email |
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| Firm |
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| File # |
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| Street Address |
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| City |
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| State |
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Zip Code |
| Phone |
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| Fax |
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| Plaintiff |
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| Claimant(s) |
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| Attorney |
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| Firm |
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| File # |
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| Street Address |
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| City |
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| State |
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Zip Code |
| Phone |
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| Fax |
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| Email Address |
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Will a Structured Settlement Broker be attending?
If yes, please list in "Other Parties" section. |
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| Other Parties |
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| Select Type |
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| Insured/Claimant |
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| Representative/Attorney/Broker |
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| Insurance Company/Firm |
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| Claim/File # |
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| Street Address |
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| City |
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| State |
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Zip Code |
| Phone |
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| Fax |
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| Email Address |
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| Other Parties |
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| Select Type |
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| Insured/Claimant |
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| Representative/Attorney/Broker |
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| Insurance Company/Firm |
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| Claim/File # |
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| Street Address |
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| City |
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| State |
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Zip Code |
| Phone |
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| Fax |
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| Email Address |
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| Case Information |
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| Date of Loss |
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| In Suit |
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| Last Offer |
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| Last Demand |
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| Type of Dispute |
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| Issues: Liability |
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| Issues: Damages |
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| Procedure Requested |
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| Have all Parties Agreed to this Procedure? |
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| Choice of Neutral |
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| 1st Choice |
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| 2nd Choice |
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| 3rd Choice |
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Special Instructions |
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