ILLINOIS NONPARTICIPATING FACILITY-BASED PHYSICIANS AND PROVIDERS / INSURER OR HEALTH PLAN Demand for Arbitration Pursuant to Illinois Insurance Code, Section 356z.3a TO: Name of Respondent Address City Phone No. Email Address: THE NATURE OF THE DISPUTE State Fax No. Zip Code Name of Representative (if known) Representative's Address City Phone No Email Address: State Fax No. Zip Code DOLLAR AMOUNT OF CLAIM $ Other Relief Sought: Attorneys Fees Interest Arbitration Cost Amount enclosed $_________________ in accordance with the Standard Fee schedule Type of Business: Claimant:_________________________________ Respondent:_______________________________ You are hereby notified that a copy of this Demand is being filed with the American Arbitration Association with a request that it commence administration of the arbitration. The AAA will provide you notice of your opportunity to file an answering statement. Signature (may be signed by a representative) Name of Claimant Title Date Name of Firm (if Applicable) Name of Representative Address (to Be Used in Connection with This Case) City Phone No. Email Address: State Fax No. Zip Code Representative's Address City Phone No. Email Address: State Fax No. Zip Code To begin proceedings, please send a copy of this Demand, along with the filing fee as provided for in the Rules to: American Arbitration Association, Case Filing Services, 1101 Laurel Oak Road, Suite 100, Voorhees, NJ 08043. Send the original Demand to the Respondent. Also send a copy of this Demand to the Illinois Department of Insurance at doi.arbitrationrequest@illinois.gov. Please visit our website www.adr.org if you would like to file a case online. AAA Case Filing Services can be reached at 1-877495-4185. American LegalNet, Inc. www.FormsWorkFlow.com