Case Submission Form


To submit this form online, please fill in all the necessary fields below and click on "Submit" to submit the form.

If you wish to fax your information to us, simply print this page from your browser, fill in the necessary information and fax to: 866.591.7482.


Name:  
Title:  
Company/Firm Name:  
Address:  

City, State, Zip:

   , ,
Telephone:  
Fax:  
E-mail Address:  
Company/Firm's Web address (URL):  
Submitting party is:  
If other, explain:  

Case Information

Please provide a brief description of the case including issues in controversy or dispute, (i.e.. amount in controversy; relief sought) history and status of settlement discussions, if any, and special information relevant to the choice of ADR process and neutral.

In litigation:   Yes No
If yes, supply case number:  

 

 

Plaintiff/Claimant Information

Name:  
Title:  
Company/Firm Name:  
Address:  

City, State, Zip:

   , ,
Telephone:  
Fax:  
E-mail Address:  
Attorney Representative:  

 

Defendant Information

Name:  
Title:  
Company/Firm Name:  
Address:  

City, State, Zip:

   , ,
Telephone:  
Fax:  
E-mail Address:  
Attorney Representative:  
     
Insurance Carrier Name
(if any):		  
Address:  
Telephone:  
Fax Number:  
Handling Claim Representative:  
Claim Number:  

 

Other Parties to the Dispute:

List Parties Who Have Agreed to Use ADR:

Hearing Format Desired:

Non-Binding/Mediative Processes:  
OR Binding/Adjudicative Processes:  
OR Other:  

AAMS Neutral(s) Desired

1st Choice:  
2nd Choice:  
3rd Choice:  
    Don't know. Please submit names of neutrals suitable for my case.

Dates Desired