CASE SUBMISSION The Filing Party is   Claim Representative Plaintiff Attorney Defense Attorney Legal Assistant Defendant     Insured   Claim #   Claim Representative   Insurance Company   Street Address   City   State        Zip Code    Phone   Fax   Email Address   Defense Attorney   Defense Attorney Email   Legal Assistant   Legal Assistant Email   Firm   File #   Street Address   City   State        Zip Code    Phone   Fax   Plaintiff     Claimant(s)   Attorney   Firm   File #   Street Address   City   State        Zip Code    Phone   Fax   Email Address   Will a Structured Settlement Broker be attending? If yes, please list in "Other Parties" section.   No Yes Other Parties     Select Type   Plaintiff Defendant Structure Broker Insured/Claimant   Representative/Attorney/Broker   Insurance Company/Firm   Claim/File #   Street Address   City   State        Zip Code    Phone   Fax   Email Address   Other Parties     Select Type   Plaintiff Defendant Structure Broker Insured/Claimant   Representative/Attorney/Broker   Insurance Company/Firm   Claim/File #   Street Address   City   State        Zip Code    Phone   Fax   Email Address   Case Information     Date of Loss   In Suit   Yes No Last Offer   Last Demand   Type of Dispute   Issues: Liability   Yes No Issues: Damages   Yes No Procedure Requested   Mediation Telemediation High/Low Arbitration Arbitration Paper Arbitration Med/Arb Private Jury Trial Judicial Referee Apellate Insight Evaluation Roundtable Interactive Survey Class Actions Have all Parties Agreed to this Procedure?   No Yes Choice of Neutral     1st Choice Selection #1 Kenneth A. Cardone, Esq. James P. Chrisman, Esq. Tom F. Deaver, Esq. Keith E. Galliher, Jr., Esq. Yolanda M. Jackson, Esq. Joseph F. Kyle, Esq. Bryan W. Lewis, Esq. George R. Lyles, Esq. Bert O. Mitchell, Esq. Anthony J. Montisano, Jr., Esq. Henry H. Rawlings, Jr., Esq. Hon. Robert L. Sklodowski (ret.) Jay Young, Esq. 2nd Choice Selection #2 Kenneth A. Cardone, Esq. James P. Chrisman, Esq. Tom F. Deaver, Esq. Keith E. Galliher, Jr., Esq. Yolanda M. Jackson, Esq. Joseph F. Kyle, Esq. Bryan W. Lewis, Esq. George R. Lyles, Esq. Bert O. Mitchell, Esq. Anthony J. Montisano, Jr., Esq. Henry H. Rawlings, Jr., Esq. Hon. Robert L. Sklodowski (ret.) Jay Young, Esq. 3rd Choice Selection #3 Kenneth A. Cardone, Esq. James P. Chrisman, Esq. Tom F. Deaver, Esq. Keith E. Galliher, Jr., Esq. Yolanda M. Jackson, Esq. Joseph F. Kyle, Esq. Bryan W. Lewis, Esq. George R. Lyles, Esq. Bert O. Mitchell, Esq. Anthony J. Montisano, Jr., Esq. Henry H. Rawlings, Jr., Esq. Hon. Robert L. Sklodowski (ret.) Jay Young, Esq. Special Instructions