DISASTER RECOVERY CLAIMS RESOLUTION SERVICES MEDIATION SUBMISSION FORM Name of Insured Address Name of Representative (if known) Name of Firm (if applicable) Representative's Address City Phone No. Email Address: State Zip Code Fax No. City Phone No. Email Address: State Zip Code Fax No. 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) Name of filing Insurance Company Address (to be used in connection with this case) City Phone No. Email Address: State Zip Code Fax No. Date: Name of Representative Name of Firm (if applicable) Representative's Address City Phone No. Email Address: State Zip Code Fax No. 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