Disaster Recovery Claims Resolution Services Mediation Submission Form
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Disaster Recovery Claims Resolution Services Mediation Submission Form. This is a Official Federal Forms form and can be use in Disaster Recovery Claims American Arbitration Association.
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DISASTER RECOVERY CLAIMS RESOLUTION SERVICES
MEDIATION SUBMISSION FORM
Name of Insured
Name of Representative (if known)
Address
Name of Firm (if applicable)
Representative’s Address
City
State
City
Fax No.
Phone No.
Zip Code
Phone No.
Email Address:
State
Zip Code
Fax No.
Email Address:
The parties agree to submit this matter in accordance with the Disaster Recovery Claims Mediation Procedures of the American
Arbitration Association. All cases will be handled by the AAA’s Central Case Management Center located in Dallas, TX. The written
submission, filed by the Insurance Company, should be sent to:
Tracey Hegeman, Assistant Vice President,
American Arbitration Association,
13455 Noel Road, Suite 1750, Dallas, Texas.
Contact information: HegemanT@adr.org
Phone. 800.426.8792; Fax. 972.490.9008
An Insurer may also file electronically using AAAWebFile®, available at www.adr.org, together with the appropriate case filing fees.
(See below for information on Administrative Fees and Mediator Compensation.)
Please indicate
Policy Number
Claim Number (check one) __________________________________
DAMAGE INCURRED:
CLAIM OR RELIEF SOUGHT (amount, if any):
If an in-person mediation session is requested, please indicate the locale: __________________________________________
Signature (may be signed by a representative)
Date:
Name of Representative
Name of filing Insurance Company
Name of Firm (if applicable)
Address (to be used in connection with this case)
Representative’s Address
City
Zip Code
City
Fax No.
Phone No.
Phone No.
Email Address:
State
State
Zip Code
Fax No.
Email Address:
To begin proceedings, the Insurance Company should send two copies of this Submission, the agreement of the parties to mediate, and
the filing fee as stated below, to the AAA. Send the original Submission to the insured.
Case filing fee for Home Owner Disputes:
$50 direct appointment of Mediator OR $100 for submission of a list of mediators for selection
Mediators Compensation: $250 for a two-hour telephonic or email conference OR $350 for two-hour in person conference
Case filing fee for Business Disputes less than $75,000
$100 direct appointment of Mediator OR $150 for submission of a list of mediators for selection
Mediators Compensation: $250 for a two-hour telephonic or email conference OR $350 for two-hour in person conference.
AAA Customer Service can be reached at 800.778.7879
American LegalNet, Inc.
www.USCourtForms.com
