en-USThe named Claimant(s), pursuant to M.S.A. 65B.525, hereby tender(s) the following dispute arising out of a no-fault insurance policy for en-USresolution under the Minnesota No-Fault Rules of Procedures administered by the American Arbitration Association (AAAen-US256en-US). en-USIn order to begin processing a no-fault arbitration case, the American Arbitration Association (AAA) requires the following be 037led with en-USthe AAA, pursuant to Minnesota No-Fault Arbitration Rules 5(c) and 5(e): 1. þ en-USFiling Fee: en-USA $40.00 037ling fee payment made payable to American Arbitration Association.en-USYour 037ling should include en-USoneen-US copy of the below documents: 2. þ en-USPetition: en-USA Completed Petition for No-Fault Arbitration, signed by the claiming party or representative. 3. þ en-USDenial/Discontinuation Letter:en-US Letter from the insurance company verifying that bene037ts have been denied or discontinued. en-US en-USIf a denial letter has not been provided, the 037ling party may submit proof that bills have been submitted to the insurance en-US en-UScompany and remain unpaid after 30 days. 4. þ en-USItemization of the Claim:en-US An itemization detailing what you are claiming for arbitration. The itemization, depending on the en-USnature of your claim, should include the name(s) of medical providers, the name(s) of employer(s), date(s) of service or loss and en-USthe amount(s) claimed for each. 5. þ en-USSupporting Documents:en-US Documentation supporting your claim. e.g. billing summaries, wage stubs, market value comparisons, etc.en-USFile through mail: en-USAmerican Arbitration Association, 700 U.S. Bank Plaza, 200 South Sixth Street, Minneapolis, MN 55402 or online by en-USvisiting en-USwww.adr.org/Supporten-US and clicking en-USSign in to Access & Manage a Case. en-USFor questions contact us at 612-332-6545. en-USClaimant Informationen-USName(s) of Claimant(s): en-US Minor:en-US en-US en-USYes en-US en-US en-USNoen-USAddress: en-USCity: en-USState: en-USZip Code: en-USPhone Number(s): en-USEmail: en-USIf the person 037ling this petition is different than the claimant named above, please complete the below information:en-USName: en-US en-USAddress: en-USCity: en-USState: en-USZip Code: en-USClaim Informationen-USInsurance Company: en-USClaim #: en-USAddress: en-USPolicy #: en-USCity: en-USState: en-USZip Code: en-USPolicyholder: en-USClaims Representative: en-USPhone: en-US*en-USTotal Amount Claimed: en-USAccident Date: en-USRequested Hearing Location: en-USRepresentative Informationen-USIf an attorney or other named individual will be representing you, please complete the below section:en-USRepresentative: en-USFirm (if applicable): en-USAddress: en-USCity: en-USState: en-USZip Code: en-USEmail: en-USPhone: en-USFax: en-USI af037rm that the information contained herein is true to the best of my knowledge. en-USSignature (Must be signed by Claimant or Representative of Claimant): en-US en en-USDate: en-US en American LegalNet, Inc. www.FormsWorkFlow.com