American Arbitration Association Disaster-Related Business Insurance Claims Claim Referral Form To refer a potential or existing claim to the American Arbitration Association, please complete information below and forward to the fax number listed at the bottom of this form. We will contact the other party and determine if they are willing to submit the claim to the AAA for resolution. Procedure Requested: Telephonic Mediation In-Person Binding Arbitration Your Business Name:_________________________________ Business Type: _______________________________________ Name of Insurer: _______________________________ Total Claim (in dollar amount):$__________________________ In-Person Mediation Binding Desk Arbitration (Documents only) Nature of Claim: (attach additional sheet if needed) ___________________________________________________________ If In-Person Option is Selected, please indicate possible site: ___________________________________________________ We agree that, if binding arbitration is selected, we will abide by and perform any award rendered hereunder and that a judgment may be entered on the award. We agree that, for any process selected, that we will abide by the Supplemental Rules and will endeavor to expedite this process. ________________________________________________ Name of Claimant _____________________________________________________ Address _____________________________________________________ City/State/Zip _____________________________________________________ Phone Fax _____________________________________________________ E-mail _____________________________________________________ Name of Attorney or Representative (if applicable) _____________________________________________________ Name of firm _____________________________________________________ Address _____________________________________________________ City/State/Zip _____________________________________________________ Telephone Fax _____________________________________________________ E-mail Company we should contact: _________________________ Date _____________________________________________________ Name of Insured or Insurance Company _____________________________________________________ Address _____________________________________________________ City/State/Zip _____________________________________________________ Phone Fax _____________________________________________________ E-mail _____________________________________________________ Name of Attorney or Representative (if applicable) _____________________________________________________ Name of firm _____________________________________________________ Address _____________________________________________________ City/State/Zip _____________________________________________________ Telephone Fax _____________________________________________________ E-mail Please send a signed copy of this form to the American Arbitration Association, ATTN: Bob Matlin 225 N. Michigan Avenue, Suite 1840, Chicago, IL 60601 Fax to 312.819.0404 or call 312.616.6560 American LegalNet, Inc. www.USCourtForms.com