County    Cause/Case #
Plaintiff    Defendant
Plaintiff's Attorney, Attorney's Firm, City

Defendant's Attorney, Attorney's Firm, City

Insurance Company
Date of Arbitration
Arbitrator(s)
Doctors/Experts (Plff), Firm, City         By Report   Live Testimony

Doctors/Experts (Def), Firm, City         By Report   Live Testimony

Date and Facts of Accident

Injuries

Age of Plaintiff:
Permanent Injury?  YesNo
If No, approximate length of treatment
Medical Expenses $   Lost Wages $
Property Damage $    Miscellaneous $
Demand $   Offer $   
Gross Award $     Contributory neg. %      Net $
Or Defense Award?  Yes No  Admitted Liability?  Yes   No
Trial de novo requested by
Report submitted by
Address
City State Zip
Phone
Email