Enter Case Information
(Please include full case caption, date of loss and your file/claim number)

Enter Plaintiff Information
(Please include firm name and address, handling attorney and phone and fax number)

Enter Defendant Information
(Please include carrier name and address, handling claim representative, phone, fax and claim number)

Other Parties
(Please enter any co-defendant, co-plaintiff or defense counsel information)

Notes
(Please indicate any other pertinent case information)

This is the last field of this form - please verify all your information prior to clicking the submit button.