REQUEST FOR ARBITRATOR SELECT: LIST ONLY Date: Case Type (Check one.): Commercial Construction 10 ($1,500) 15 ($2,000) Number of Arbitrators to be provided (Check one.): 5 ($750) Fees are payable at the time of submission of this form. Desired Qualifications for Arbitrator(s): Please include requests for professional and/or industry expertise, geographic limitations and/or locations, and any other relevant information. Additional Case Information Dollar Amount of Claim: Dollar Amount of Counterclaim (if any): Nature of Dispute: Termination of AAA Authority With Arbitrator Select: List Only, AAA services conclude with the provision of the arbitrator list. Therefore, AAA services do not include, among other things, the handling of fees charged by the arbitrator(s), inviting arbitrator(s) to serve, performance-related matters, conflict checks and disclosures, scheduling, award-related matters or any other issues that might arise during the arbitration proceeding. Exclusion of Liability a. b. c. The parties agree that neither the AAA nor any arbitrator listed or appointed under this service is a necessary or proper party in judicial proceedings related to either the parties' arbitration or the provision of services under the AAA's Arbitrator Select. The parties agree that neither the AAA nor any arbitrator listed or appointed under this service shall be liable to any party in any action for damages or injunctive relief for any act or omission in connection with the parties' arbitration or the provision of AAA's Arbitrator Select. The parties further agree not to call the arbitrator, the AAA or AAA employees as a witness in litigation or any other proceeding relating to the arbitration for which the AAA's Arbitrator Select has been utilized. The arbitrator, the AAA and AAA employees are incompetent to testify as witnesses in any such proceeding. Credit toward Future Case Management Fees If within six months after utilizing Arbitrator Select, parties decide to receive full service case administration, they may file a case under the Standard Commercial Fee Schedule. Full credit for the amount paid for this service will be reflected in the reduced filing fee paid at the time of submission. Refunds There is a minimum non-refundable search fee of $750. If the AAA, in its sole discretion, is unable to compile an appropriate list of arbitrators after completing a search, the balance of the List Only service fees will be refunded. Requesting Party and Representative By executing the form below, all parties and their representatives acknowledge that they agree to be bound by the terms of this submission form. Party: Party's Representative Name: Address: City: Phone: Email Address: Signature (required): You may fill out this form online and email to your local AAA office or download it, fill it out, and mail it in. A listing of local offices can be found at www.adr.org/contact. Questions? Please call Customer Service at 1.800.778.7879. American LegalNet, Inc. www.FormsWorkFlow.com Nature of Business: Firm/Organization Name: State: Fax: Zip Code: