To the Respondent Insurance Company: Address: City: State: Zip Code: Telephone: Fax: Email Address: Please take notice that the 037ling party, a party to an insurance policy providing for protection against loss due to personal injuries sustained in accidents involving uninsured or hit-and-run motorists that provides for arbitration of disputes arising thereunder in accordance with the rules of the American Arbitration Association, thereby demand arbitration thereunder.The Issuing Company: Address of the Insurer Claim Of037ce: City: State: Zip Code: The Name of the Individual with Whom the Claim was Discussed: Name of Respondent222s Attorney or Law Firm: The Name of the Policyholder: Address of the Policyholder: City: State: Zip Code: Telephone: Fax: Email Address: *The Policy Number: *Effective From: *To *The Claim File Number: *Applicable Policy Limits: *Name(s) of Claimant(s): þ Check if Minor þ *Amount Claimed: If the claimant is a minor or incompetent, give the name of the legal representative: *The Date of the Accident: *Location: Type of Claim (Check one): Uninsured Motorist Hit and Run Underinsured Motorist American LegalNet, Inc. www.FormsWorkFlow.com The Nature of the Dispute and the Injuries Alleged (Attach additional sheets if necessary. Please do not include offers of settlement Previously discussed.)*Hearing Locale Requested (Give either the county of residence of the insured or the county where the accident occurred.):You are hereby noti037ed that a copy of our arbitration agreement and this demand are being 037led with the American Arbitration Association at its Case Filing Services at 1101 Laurel Oak Road, Suite 100, Voorhees, NJ 08043 with a request that it commence administration of the arbitration.Signed: (Representative) Name of Claimant222s Representative: Address: City: State: Zip Code: Telephone: Fax: Email Address: Name of Claimant: Address: City: State: Zip Code: Telephone: Fax: Email Address: The original of this demand must be served on the other party by US certi037ed mail, return receipt requested. One copy, together with one copy of the parts of the policy or regulations relating to the dispute, including the arbitration provisions, must be 037led with the AAA Case Filing Services at 1101 Laurel Oak Road, Suite 100, Voorhees, NJ 08043. The nonrefundable initial administrative fee of $450.00 should accompany the initiating papers. American LegalNet, Inc. www.FormsWorkFlow.com