First Name:

Last Name:

Email Address:

Firm Name:

Address:

City:

State:

Postal Code:

Phone Number:

Extension (if applicable):

Case Name:

Arbitration Date:

Arbitration Time:

Taking Attorney:

Estimated Length of Arbitration:

Arbitration Location/ Street Address:

Number of Veritext Conference Rooms Needed:

Corporate Account Associated?

Name of Corporate Account:

Insurance Client Associated?

Insurance Client:

Claim #/Matter #:

Adjuster:

DOL:

Notes:

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