en-USTo ensure your demand is processed promptly, please include a copy of the Arbitration Agreement, Plan or Contract. en-USMediation: en-USIf you would like the AAA to contact the other parties and attempt to arrange mediation, please check this box en-US. en-USParties (Claimant)en-USName of Claimant: en-USAddress: en-USCity: en-USState: en-USZip Code: en-USPhone No.: en-USFax No.: en-USEmail Address: en-USRepresentative222s Name (if known): en-USFirm (if applicable): en-USRepresentative222s Address: en-USCity: en-USState: en-USZip Code: en-USPhone No.: en-USFax No.: en-USEmail Address: en-USParties (Respondent)en-USName of Respondent: en-USAddress: en-USCity: en-USState: en-USZip Code: en-USPhone No.: en-USFax No.: en-USEmail Address: en-USRepresentative222s Name (if known): en-USFirm (if applicable): en-USRepresentative222s Address: en-USCity: en-USState: en-USZip Code: en-USPhone No.: en-USFax No.: en-USEmail Address: en-USClaim: What was/is the employee/worker222s annual wage range? en-US Less than $100,000 en-US $100,000-$250,000 en-US Over $250,000en-USNote: This question is required by California law.en-USAmount of Claim: en-USClaim involves: en-US Statutorily Protected Rights en-US Non-Statutorily Protected Rights American LegalNet, Inc. www.FormsWorkFlow.com en-USIn detail, please describe the nature of each claim. You may attach additional pages if necessary:en-USOther Relief Sought: en-US Attorneys Fees en-US Interest en-US Arbitration Costs en-US Punitive/ Exemplary en-US Other: en-US en-USPlease describe the quali037cations for arbitrator(s) to hear this dispute:en-USHearing: Estimated time needed for hearings overall: en-US hours or en-US daysen-USHearing Locale: en-US(check one)en-US en-US Requested by Claimant en-US Locale provision included in the contracten-USFiling Fee requirement or $300 (max amount per AAA)en-USFiling by Company: en-US $2,200 single arbitrator en-US $2,800 three arbitrator panelen-USNotice: To begin proceedings, en-USplease send a copy of this Demand and the Arbitration Agreement, along with 037ling fee as en-USprovided for in the Rules,en-US to: American Arbitration Association, Case Filing Services, 1101 Laurel Oak Road, Suite 100, Voorhees, NJ en-US08043. Send the original Demand to the Respondent.en-USSignature (may be signed by a representative): en-USDate: en-USPursuant to Section 1284.3 of the California Code of Civil Procedure, consumers with a gross monthly income of less than 300% of en-USthe federal poverty guidelines are entitled to a waiver of arbitration fees and costs, exclusive of arbitrator fees. This law applies to all en-USconsumer agreements subject to the California Arbitration Act, and to all consumer arbitrations conducted in California. Only those en-USdisputes arising out of employer plans are included in the consumer de037nition. If you believe that you meet these requirements, you en-USmust submit to the AAA a declaration under oath regarding your monthly income and the number of persons in your household. en-USPlease contact the AAA222s Western Case Management Center at1-800-778-7879. If you have any questions regarding the waiver of en-USadministrative fees, AAA Case Filing Services can be reached at 877-495-4185. Please visit our website at en-USwww.adr.orgen-US if you would en-USlike to 037le this case online. AAA Customer Service can be reached at 800-778-7879. American LegalNet, Inc. www.FormsWorkFlow.com