Please Print This Form and Fax to 866-512-6779
Case Caption: _______________________________________________________________
Claimant's Counsel: ___________________________________________________________
Respondent #1 Counsel: _______________________________________________________
Respondent #2 Counsel: ________________________________________________________
Insurer #1 and Claim Number: __________________________________________________
Insurer #2 and Claim Number: ___________________________________________________
Claim Representative #1: _______________________________________________________
Claim Representative #2: _______________________________________________________
Agreed Date For Hearing (obtained from on-line schedule): __________________________________
Submitted by: ______________________________________________________________
(Name, Firm, Telephone #)
Confirmation of scheduling will be made by telephone.