en-US1. Name of Homeowner (Please Print): en-US2. en-USAddressen-US and en-USCountyen-US of the damaged property/claim:en-USStreet: en-USCity: en-USState: en-USZip Code: en-USCounty: en-USCurrenten-US Address: Street: en-USCity: en-USState: en-USZip Code: en-USYour Phone Number (with Area Code): en-USYour Email Address: en-US3. Full Name of Insurance Company (as it appears on policy): en-USStreet: en-USCity: en-USState: en-USZip Code: en-USInsurance Co. Phone (with Area Code): en-USInsurance Co. Fax (with Area Code):en-USInsurance Co. Email: en-USInsurance Co. Contact Person: en-US4. Your Claim Number: en-USYour Policy Number: en-US5. Date on which You Received Denial Notice: en-US6. BRIEF DESCRIPTION OF THE DISPUTE, including amount(s) disputed (Attach additional sheet if necessary): Please Note: To speed en-USup the process, please complete and return this form en-USONLYen-US. Please bring any additional paperwork to the mediation conference. 225 þ Have you commenced the appeals/appraisal process under your policy? en-US Yes en-US No 225 þ If yes, have you completed the appeals/appraisal process? en-US Yes en-US No 225 þ Have you 037led any legal action with regard to this claim? en-US Yes en-US No en-USYour Signature: en-USDate: en-USIMPORTANT NOTICE:en-US Your claim might be eligible for mediation pursuant to North Carolina General Statute 58-44-70 (Senate Bill 277, Session Law en-US2006-145), which established a Mediation Program to facilitate the effective, fair, and timely handling of disputed residential property damage claims en-USarising out of declared disasters. To be eligible for the Program, the amount of the dispute (the difference between the parties) must be at least en-US$1,500, unless both parties agree to mediate a smaller claim. The program does not apply to claims denied due to policy exclusions, policy terms/en-US en-USprovisions, or policy not being in effect on the date of loss. Also, the program does not apply to commercial insurance, private passenger motor en-US en-USvehicle insurance or National Flood Insurance Program 036ood policies. All program costs are paid by the insurer. en-USComplete this form and return it to:en-USAmerican Arbitration Association en-US en-USCenter for Mediationen-USATTN: NC Disaster Mediationen-US1301 Atwood Avenue, Suite 211N, Johnston, RI 02919en-USFax to: 866.644.0234 | Email to: en-USNCDisasterMediation@adr.orgen-USResources: 225 þ Your insurance company adjustor or customer service department. 225 þ Your insurance agent. 225 þ The consumer information page on the NC Department of Insurance website: en-USwww.ncdoi.comen-US. 225 þ The general information on mediation page on the American Arbitration Association222s website: en-USwww.adr.orgen-US. American LegalNet, Inc. www.FormsWorkFlow.com