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Sample Issue
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Arbitration Reporting Form
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County:
*
Cause/Case No:
Plaintiff(s):
*
Defendant(s):
*
Date of Arbitration:
*
Arbitrator(s):
Plaintiff Attorney:
*
Plaintiff Attorney Firm:
Plaintiff Attorney City:
Defendant Attorney:
*
Defendant Attorney Firm:
Defendant Attorney City:
Insurance Company:
Doctors/Experts (Plff), Specialty, City:
Live Testimony
By Report
Doctors/Experts (Def.), Specialty, City:
Live Testimony
By Report
Plaintiff Age:
Gender:
Male
Female
Admitted Liability?:
Yes
No
Date of Loss:
Factual Description:
*
Injuries (Fractures, Surgeries, etc.):
*
Permanent Injury?:
Yes
No
If no, length of treatment:
Medical Expenses $:
*
Lost Wages $:
Property Damage $:
Miscellaneous $:
Demand $:
Offer $:
Gross Award $:
*
Contributory Neg%:
Net $:
Or Defense Award?:
Yes
No
Trial De Novo requested by:
Report Submitted By:
*
Telephone:
*
Email:
