Arbitration Associates, Inc. Case Submission Form

(Click on this side of the page, then print this form)

11902 Markey Circle - Midlothian, VA 23112 - (804) 763-3600 - (804) 639-9393 - Fax (804) 763-3700

Today’s Date

Submitting Party (Your Name)

Case Type:

PROGRAM REQUESTED: (check all that apply)

BINDING

NON-BINDING

OTHER
Standard Arbitration [] High/Low Arbitration [] Documents Only Arb. [] Mediation [] Settlement Conference [] Early Neutral Evaluation []
Plaintiff / Claimant: Defendent / Opposing Party:
Attorney: Rep. Name:
Carrier:
Firm: Law or Claim #
Address: Address:
Suite: Suite:
City: ST: Zip: City: ST:         Zip:       
Phone: Phone:
FAX: FAX:
DATE OF LOSS: Opposing Attorney:
Location (City or County/State):
[]-Damages []-Liability []-Liability & Damages Firm:
[]-Suit Filed []-Suit Served Trial Date: Address:
Suite:
Offer/Low: $ Demand/High: $ City: ST: ZIP:
Phone:
FAX:
Cases may be FAXED, PHONED, OR MAILED IN. Include any comments or special instructions here or on a separate attachment. If you have any questions, do not hesitate to call. We look forward to serving you.
Special instructions: