Corporate Headquarters
1550 N. Prospect Ave.
Milwaukee, WI 53202
(800) 776-6060
info@resolutesystems.com
CASE SUBMISSION
The Filing Party is  






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.		  






Other Parties    
Select Type  
Insured/Claimant  
Representative/Attorney/Broker  
Insurance Company/Firm  
Claim/File #  
Street Address  
City  
State        Zip Code   
Phone  
Fax  
Email Address  






Other Parties    
Select Type  
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  
Last Offer  
Last Demand  
Type of Dispute  
Issues: Liability  
Issues: Damages  






Procedure Requested  






Have all Parties Agreed to this Procedure?  







Special Instructions