Case Name *
Date Submitted
Submitted By *
Phone *	e-mail *
CO/Firm *

Plaintiff Information

Plaintiff *
Attorney *
Firm *
Address	City State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip
Phone *	Fax* e-mail

Defendant Information

Defendant *
Attorney *
Firm *
Address	City State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip
Phone *	Fax * e-mail

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Additional Parties

Name
Attorney
Firm
Mailing Address
City	State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip
Phone	Fax
Email
Additional Comments

Name
Attorney
Firm
Mailing Address
City	State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip
Phone	Fax
Email
Additional Comments

Case Information

Type of Case Choose one PI/BI Auto WC Med Mal Slip/Fall Fatality Property Dispute Products Liability Employment Business Contract Dispute Construction Family Law Community Issues Other Is this case in Litigation Yes No Is this case Court Ordered Yes No

Judge's Name Cause No.

Court No. Trial Date

Session Information

Full Day Half Day 1 1/2 Hr.

Mediator Preference/Court Ordered Mediator Enter Three Date Preferences Below