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Case Submission Form

Please fill out the form with as much detail as possible. Fields marked (required) are mandatory.
* If any party in a binding arbitration is not represented by counsel, please contact a case manager at Judicate West before submitting a dispute.

Submitting Party	(required)
Email	(required)
Case Caption	(required)

1. Fill in the information for all active parties
a.	PLAINTIFF
Plaintiff Name	(required)
Attorney Name
Firm Name
Firm Case #
Firm Address
Phone Number
Fax Number
b.	DEFENDANT
Defendant Name	(required)
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
Insurance Company Phone Number
Insurance Company Fax Number
c.	OTHER PARTY
Type	Plaintiff 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

Non-Binding Mediation
Formal Arbitration
Judicial Arbitration (non-binding)
UM/UIM Arbitration
Voluntary Settlement Conference
Private Trial
Discovery Referee / Special Master
Other

Personal Injury
Commercial
Other

None
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Advanced
Complete

www.judicatewest.com

12400 Wilshire Blvd. Suite 850
Los Angeles, CA 90025
Phone (310) 442-2100
Fax (310) 442-2125

1851 E. First Street. Suite 1600
Santa Ana, CA 92705
Phone (714) 834-1340, (800) 488-8805
Fax (714) 834-1344

1 World Trade Center Suite 1650
Long Beach, CA 90831
Phone (562) 432-8340
Fax (562) 432-8344

402 West Broadway Suite 2000
San Diego, CA 92101
Phone (619) 814-1966
Fax (619) 814-1967

660 S. Figueroa St. Suite 1910
Los Angeles, CA 90017
Phone (213) 223-1113
Fax (213) 223-1114

	1851 E. First Street Suite 1600 Santa Ana, CA 92705 Phone: (800) 488-8805 Fax: (714) 834-1344

Results Beyond Dispute	www.judicatewest.com