Case Submission Form




 
Please fill out the form with as much detail as possible. Fields marked with '*' are mandatory.
* If any party in a bind arbitration is not represented by counsel, please contact a case manager at Judicate West before submitting a dispute.
Submitting Party* :
Case Caption* :

1. Fill in the information for all active parties.
 2. Indicate Type of Hearing.
a. PLANTIFF
Plaintiff Name*
Attorney Name
Firm Name
Firm Case #
Firm Address
Phone Number
Fax Number

b. DEFENDANT INSURANCE CARRIER
Defendant Name*
Attorney Name
Firm Name
Firm Case #
Firm Address
Phone Number
Fax Number
Insurance Company
Claim Number
Date of Loss
Claim Rep Name
Insurance Company
Address
Phone Number
Fax Number

c. OTHER PARTY Plantiff Defendant
Party Name
Attorney Name
Firm Name
Firm Case Number
Firm Address
Phone Number
Insurance Company
Claim Number
Claim Rep Name
Supervisor Name
Insurance Company
Address
Insurance Company
Phone Number

E-mail Addresses
Informal Arbitration / "Binding Mediation"
UM/UIM Arbitration
Judicial Arbitration (non-binding)
Formal Arbitration
Non-Binding Mediation
Voluntary Settlement Conference
Discovery Referee / Special Master
Other

3. Estimated Hearing Length Hours Day(s)

4. Additional Case Information
a. Personal Injury Commercial Other
b. Brief description of claim
c. Is liability an issue? Yes No
d. Stage of Investigation or Discovery:
None Basic Advanced Complete
e. Has suit been filed? Yes No
f. Last offer and Demand:
Offer   Demand  
g. Suggested High/Low Amounts:
High   Low  
h. Date of last contact :
i. Has alternate dispute resolution been discussed?
Yes No
j. Have all parties agreed to use JUDICATE WEST?
Yes No
k. Additional Information
Agreed Neutrals
Requested Neutrals

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Fax (213) 223-1114




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Any questions? Please email it to team@adjudicateinc.com