American Arbitration Association Hurricane Ernesto Damage Claim Mediation Request for Duplin and Jones Counties 1.Name of Homeowner (Please Print): 2. Address and County of the damaged property/claim: Street City State Current Address: Street City State Your Phone Number (with Area Code): Zip County Zip Your Email Address: 3. Full Name of Insurance Company (as it appears on policy): Address of Insurance Company: Street City State Zip Insurance Co. Email: Insurance Co. Contact Person: Your Policy Number: Insurance Co. Phone (with Area Code): Insurance Co. Fax (with Area Code): 4. Your Claim Number: 5. Date on which You Received Denial Notice: 6. BRIEF DESCRIPTION OF THE DISPUTE, including amount(s) disputed (Attach additional sheet if necessary): Please Note: To speed up the process, please complete and return this form ONLY. Please bring any additional paperwork to the mediation conference. · · · Have you commenced the appeals/appraisal process under your policy? If yes, have you completed the appeals/appraisal process? Have you filed any legal action with regard to this claim? Yes Yes Yes No No No YOUR SIGNATURE: DATE: IMPORTANT NOTICE: Your claim might be eligible for mediation pursuant to North Carolina General Statute 58-44-70 (Senate Bill 277, Session Law 2006-145), which established a mediation program to facilitate the effective, fair, and timely handling of disputed residential property damage claims arising out of declared disasters. To be eligible for the program, a disputed claim must be requesting at least $1,500, or the difference between the parties must be at least $1,500. The program does not apply to claims denied due to policy exclusions, policy terms/provisions, or policy not being in effect on the date of loss. Also, the program does not apply to commercial insurance, private passenger motor vehicle insurance or National Flood Insurance Program flood policies. All program costs are paid by the insurer. Complete this form and return it to: American Arbitration Association Center for Mediation ATTN: NC Insurance Mediation 13455 Noel Road, Suite 1750 Dallas, TX 75240 Or Fax to: 972-702.0173 Resources: Your insurance company adjustor or customer service department. Your insurance agent. The consumer information page on the NC Department of Insurance website: www.ncdoi.com The general information on mediation page on the American Arbitration Association's website: www.adr.org. American LegalNet, Inc. www.FormsWorkFlow.com