American tration ociation Arbi Ass D i s p u t eR e s o l u t i o n e r a i c e s o r l d w i d e S W American Arbitration Association/ Joint Resolution, LLC Proceduresfor Resolutionof U.S. ReinsuranceDisputes REINSURAI\CE DISPUTESUBMISSIOI\ FORM The namedparties hereby submit the following disputeto binding arbitration,under the American Arbitration Association/Joint Resolution,LLC procedures the Resolution U.S. Reinsurance for of Disputes. I{ATURE OF DISPUTE: OtherRelief Soueht: ! Attorneys Fees Dollar Amount of Claim: I hterest I Arbitration Costs I Punitive/Exemplary !Other PLEASE FILE TWO SIGNED COPIES ALONG W]TH TIIE FILING FEE AS PROVIDED FOR IN THE PROCEDIJRES,TO TFXE AAA. Amount of fiiing fee enclosed with this submission (please refer to the fee schedule in the procedures for the appropriate fee) We agreethat we will abideby andperform any awardrendered hereunder that ajudgrnentmay be entered and on the award. Name of Partv Address: Name of Party Address: City: State Zip Code City: State Zip Code PhoneNo. Email Address: Signature(required): Fax No. PhoneNo. Email Address: Signature(required): Nameof Representative: Name of Firm (if applicable) Fax No. Name of Representative : Nameof Firm (if applicable) Address(to be usedin connection with this case) Address(to be usedin connection with this case) City: PhoneNo. Email Address: Fax No. State Zip Code City: Phone No. State Zrp Code Fax No. Email Address: Please File fwo copieswith the AmericanArbitrationAssociation Reinsurance CaseManagement Center 2200 CenturyParkway,Suite 300 Atlanta,GA 30345 (800) 92s-0rss American LegalNet, Inc. www.FormsWorkFlow.com