American Arbitration Association Special Non-Binding Arbitration Program Request Form 1.Name of Homeowner (Please Print): 2. Address and County of the damaged property/claim: Current Address: Phone: ( ) 226 Email: 3. Name of the Insurer: Address: Phone: ( ) - Fax: ( ) - Email: Contact Person: 4. Claim Number: Policy Number: 5. Is this claim under a flood policy: Yes No 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. Have you commenced the appeals/appraisal process under your policy? Yes No If yes, have you completed the appeals/appraisal process? Yes No Have you filed any legal action with regard to this claim? Yes No SIGNATURE: DATE: IMPORTANT NOTICE You are entitled to arbitration pursuant to the Mississippi Department of Insurance Emergency Regulation No.: 2007-3 which sets forth a arbitration procedure for a facilitated claims resolution conference prompted by the critical need for effective, fair, and timely handling of personal lines insurance claims arising out of damages to property caused by Hurricane Katrina during the 2005 hurricane season. The procedure does not apply to commercial insurance, private passenger motor vehicle insurance, or National Flood Insurance Program flood policies. This procedure applies to claims where the difference between the positions of the parties is $5000.00 or more. All costs are paid by the insurer. Complete this form and return it to: American Arbitration Association ATTN: MS Insurance Arbitration 13455 Noel Road, Suite 1750 Dallas, TX 75240 Or Fax to: 972-490.9008 MSinsarbitration@adr.org Resources: Your insurance company adjustor or customer service department. Your insurance agent. The consumer information page on your Mississippi Department of Insurance website: www.doi.state.ms.us. The general information on the American Arbitration Association222s website: www.adr.org. American LegalNet, Inc. www.FormsWorkFlow.com