AMERICAN ARBITRATION ASSOCIATION Supplementary Rules for the Resolution of Intra-Industry U.S. Reinsurance and Insurance Disputes Reinsurance and Insurance Dispute Submission Form To institute proceedings, please send two copies of this submission, and the dispute resolution provision in the contract (if applicable), along with the proper filing fee to the AAA (please see above-entitled rules for proper fee). Date:_______________________ Type of Business: Claimant (Party 1) Insurer Reinsurer Retrocessionaire _____________________ Respondent (Party 2) Insurer Reinsurer Retrocessionaire _____________________ The parties jointly agree to submit the underlying dispute to the American Arbitration Association for the purpose of selecting the neutral umpire under the AAA’s Umpire Selection Procedures. Please indicate level of service required: or The claimant (party 1) unilaterally submits the underlying dispute to the American Arbitration Association for the specific service selected. The claimant acknowledges the presence of a dispute resolution provision named in the parties’ contract which specifically includes the AAA’s Rules or Procedures. A copy of the provision is enclosed. List Only List with appointment Complete AAA administration (Note: the American Arbitration Association cannot proceed upon the unilateral request of one party unless the AAA’s Rules or Procedures are specifically named in contract). _______________________________________ ________________________________________ Claimant (Party 1) (Party 2) Respondent _______________________________________ ________________________________________ Address Address _______________________________________ ________________________________________ City/State/Zip City/State/Zip ( ) _________________________________ Telephone Fax _______________________________________ ( ) __________________________________ Telephone Fax ________________________________________ Name of the Party’s Attorney or Representative Name of the Party’s Attorney or Representative _______________________________________ ________________________________________ Address Address _______________________________________ ________________________________________ City/State/Zip City/State/Zip ( ) _________________________________ Telephone Fax ____________________________________________________ Signed (may be signed by a representative) Title ( ) __________________________________ Telephone Fax _____________________________________________________ Signed (may be signed by a representative) Title Please file two copies with the American Arbitration Association Southeast Case Management Center 2200 Century Parkway, Suite 300 Atlanta, GA 30345 800/925-0155 American LegalNet, Inc. www.FormsWorkflow.com