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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

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

Personal Injury
Commercial
Other

None
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Advanced
Complete

www.judicatewest.com

12100 Wilshire Blvd. Suite 650
Los Angeles, CA 90025
Phone (310) 442-2100
Fax (310) 442-2125

1851 E. First Street. Suite 1450
Santa Ana, CA 92705
Phone (714) 834-1340, (800) 488-8805
Fax (714) 834-1344

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Long Beach, CA 90831
Phone (562) 432-8340
Fax (562) 432-8344

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San Diego, CA 92101
Phone (619) 814-1966
Fax (619) 814-1967

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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