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Submitter Information
Your Name:
Date Submitted:
Your Firm:
Your Telephone with Area Code:
Extension:
This firm represents:	Choose one ---> Plaintiff Defendant Interested Third Party

Case Information
Venue (Include City/County):
Claim Type:	Choose one ---> Auto Civil Rights Condemnation Contract F. E. L. A. Intentional Tort Jones Act Malpractice (Medical, Dental, Legal, Accountant) Premises Liability Products Liability Property Damage
Other Type of Claim (If not listed above):
Parties in Case:
Case Number:
Division:
Judge:

Plaintiff's Trial Counsel
Plaintiff's Attorney:
Plaintiffs Law Firm:
Address:
City:
State:
ZIP Code:
Telephone:
Extension:
Fax:
Email:
Represented which party?
Other Trial Counsel:

Defendant's Trial Counsel
Defendant's Attorney:
Defendant's Law Firm:
Address:
City:
State:
ZIP Code:
Telephone:
Extension:
Fax:
Email:
Represented which party?
Other Trial Counsel:

Case Details
Facts of Case (Describe claim, plaintiff's allegations and liability issues, street names and direction of travel for auto):
Plaintiff's Age at Time of Incident:
Facts of Case (Describe claim, defendant's allegations and liability issues, street names and direction of travel for auto):
Time of Day:	Choose one ---> Day Night
Weather Conditions:
Defendant's Insurer:
Plaintiff's Alleged Injuries and/or Damages:
Plaintiff's Medical Specials:
Plaintiff's Wage Loss:
Plaintiff's Property Damage:
Damages in Counterclaim:

Plaintiff's Expert Information
Plaintiff's Expert #1:
Specialty:
City:
State:
Expert or Treating:	Choose one ---> Treating Doctor Examining Doctor Hired Expert
Live Testimony or By Deposition:	Choose one ---> Live Testimony By Depo. By Video Depo.
Plaintiff's Expert #2:
Specialty:
City:
State:
Expert or Treating:	Choose one ---> Treating Doctor Examining Doctor Hired Expert
Live Testimony or By Deposition:	Choose one ---> Live Testimony By Depo. By Video Depo.
Plaintiff's Expert #3:
Specialty:
City:
State:
Expert or Treating:	Choose one ---> Treating Doctor Examining Doctor Hired Expert
Live Testimony or By Deposition:	Choose one ---> Live Testimony By Depo. By Video Depo.
Other Experts for Plaintiff (Include name, specialty, city, state, treating/expert and live/depo.)

Defendant's Expert Information
Defendant's Expert #1:
Specialty:
City:
State:
Expert or Treating:	Choose one ---> Treating Doctor Examining Doctor Hired Expert
Live Testimony or By Deposition:	Choose one ---> Live Testimony By Depo. By Video Depo.
Defendant's Expert #2:
Specialty:
City:
State:
Expert or Treating:	Choose one ---> Treating Doctor Examining Doctor Hired Expert
Live Testimony or By Deposition:	Choose one ---> Live Testimony By Depo. By Video Depo.
Defendant's Expert #3:
Specialty:
City:
State:
Expert or Treating:	Choose one ---> Treating Doctor Examining Doctor Hired Expert
Live Testimony or By Deposition:	Choose one ---> Live Testimony By Depo. By Video Depo.
Other Experts for Defendant (Include name, specialty, city, state, treating/expert and live/depo.)

Conclusions
Last Demand to Settle:
Last Offer to Settle:
Date of Verdict:
Verdict/Judgement/Settlement:
Apportioned Fault to Plaintiff:	%
Apportioned Fault to Defendant:	%
Award gross amount:	$
Award net amount:	$
Post Trial Motions:
Filed By:
Decision:
Appeal:
Editorial Comments:

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