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ADR SUBMITTAL FORM

Submitting the following information at this time will help us to process your referral quickly and efficiently. Click here to download and print this file using Adobe Acrobat Reader®. You can also just complete the portions of this form noted with an asterisk and then simply fax me a proof of service, noting which counsel is representing the respective parties. That will enable me to have all of the parties to the dispute as well as the court¹s case number, so I can prepare a confirming letter and copy any necessary Court ADR Administrator. Note: This form is sent through a secure server. Thank you.

Note - all fields marked with an asterisk (*) are required.

 
Referred By:
Case Name*: Billing File No:

Important Dates:

Arb. STC. Trial: Other:
Submitting Co./Atty./Ins. Claims: Date submitted*:
Time you will set aside for ADR session: (hours) Est. time to try case: (court days)
Your address*:
Phone*: E-Mail: Fax*:
 
Claims representative: Title:
Claims phone: E-Mail: Fax:
Insurance carrier:
Carrier address:
Your principle/insured/client*:
* Plaintiff Defendant CrossDefendent Other 
Type of case/dispute: Date of Loss:
Client's Role in Dispute:
Brief summary of facts and procedural status of file:
Please briefly note any pivotal legal or procedural issues, if applicable, that may have a bearing on resolution of this case:
Most recent demand of Pl:
Most recent offer:
Status of settlement negotiations:
Status of related cross-actions and any pertinent contract issues:
Additional discovery needed before ADR can be effective:
Which parties have agreed to mediate?
Have the parties made any non-pro-rata cost sharing arrangements?
Additional Information:
Parties: If you do not complete the following section, please provide a current Proof of Service showing all parties, their telephone numbers and their respective role in the dispute. You may attach this as a Word document to an e-mail to me at venneradr@msn.com, or you can fax it to me at (415) 388-1036. Thank you.
 
Party Name: Atty. Name:
Pltf Def Other Firm:
Role in Dispute: Firm Address:
Carrier:
Representative: Billing File Number:
Phone: Fax: E-Mail:
 
Party Name: Atty. Name:
Pltf Def Other Firm:
Role in Dispute: Firm Address:
Carrier:
Representative: Billing File Number:
Phone: Fax: E-Mail:
 
Party Name: Atty. Name:
Pltf Def Other Firm:
Role in Dispute: Firm Address:
Carrier:
Representative: Billing File Number:
Phone: Fax: E-Mail:
 
Party Name: Atty. Name:
Pltf Def Other Firm:
Role in Dispute: Firm Address:
Carrier:
Representative: Billing File Number:
Phone: Fax: E-Mail:

Click here to download this file, but you must have Adobe Acrobat Reader ® to view it. Click on the icon below to download Adobe Acrobat Reader ®. This will enable you to print this form out and retain its formatting.

Phone: (415) 388-0905 • Fax: (415) 388-1036 • E-Mail: venneradr@msn.com
Web: http:// www.venneradr.com


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