CMA 

Century Mediation Associates, Inc.

 CMA #:
Submitted by: PL Invoice#:
Case Manager: DF Invoice #:
Date: DB   AL
ABOVE INFO FOR CMA USE ONLY

TO SUBMIT CASES JUST CALL US OR FILL IN THE INFORMATION AND FAX IT BACK.  CMA will do the rest!
1. PLAINTIFF:   3. OTHER PARTY:
Plaintiff: Name: 
Attorney: Attorney:
Firm: Firm:
Address: Address:
Phone: E-Mail:
Fax: Phone:
E-Mail: Fax:
2. DEFENDENT / INS. CARRIER: Insurance Co.:
Defendent: Address:
Attorney: Claim Number:
Firm: Claim Rep.:
Address: Phone:
Phone: Fax:
Fax: E-Mail:
E-Mail: 4. OTHER PARTY:
Insurance Co.: Name: 
Address: Attorney:
Claim Number: Firm:
Date of Loss: Address:
Claim Rep: E-Mail:
Phone: Phone:
Fax: Fax:
E-Mail: Insurance Co.:
Address:
Is Liability an issue?
Claim Number:
Has Suit been filed?
Claim Rep.:
PL agreed to ADR?
Phone:
Carrier: Is Plaintiff required to attend?
Fax:
      E-Mail:
Check Procedure: MEDIATION 1 Hour Hearing (Non-Binding) Settlement Day
ARBITRATION 1 Hour Hearing (Binding)
Latest Offer and Demand: Offer: Demand:
Suggested Parameters: High:   Low:      
Determination:  Liability Only Damages Only   Liability AND Damages 

BRIEF DESCRIPTION OF CLAIM / COMMENTS:

Submitter's E-Mail address (your e-mail)*: