American Arbitration Association NEW YORK STATE SUM/UM ARBITRATION TRIBUNALS The original of this demand must be served on the other party by of U.S. certified mail-return receipt requested. Three (3) copies of this demand, together with corresponding copies of the endorsement and declarations page, must be filed at 65 Broadway, New York, NY 10006. A non-refundable administrative fee in the amount of two hundred and fifty dollars ($250) is due and payable at the time of filing this demand. REQUEST FOR ‰SUM ARBITRATION OR ‰ UM ARBITRATION (9) CHOOSE ONE ONLY (choice of forum for resolution of the dispute is subject to the information contained in the declarations sheet, if provided) DATE: To the Respondent (The name of the Insurer) (Send the original to the party on whom the demand is being made. When filed by an insured, the original shall be sent directly to the claims office of the insurer under whose policy arbitration is sought, either the office where the claim has been discussed or the office closest to the residence of the incurred.) Address ______________________________________________________________________________________________________________ City ______________________________________ State _____________ Zip Code _____________________________________________ Telephone ( ) __________________________________ Fax ( ) _____________________________________________ PLEASE TAKE NOTICE that the filing party, a party to an insurance policy providing for protection against loss due to personal injuries sustained in accidents involving uninsured, underinsured or hit-and-run motorist that provides for arbitration of disputes, arising thereunder in accordance with the rules of the American Arbitration Association, hereby demands arbitration hereunder. The Issuing Company _______________________________________________________________________________________________ Address of the Insurer’s Claims Office (if known) Name of the Individual with Whom the Claim was Discussed Name of the Policyholder Address and Telephone Number of the Policyholder (on date of accident) Effective From Policy Number to Claim File Number Applicable Policy Limits Name(s) of Applicant (s) __________________________________ __________________________________ ________________________________________ Tortfeasor’s Policy Limits Check if a minor Amount Claimed ‰ $_______________________________ ‰ $ _____________________________ ‰ $ ______________________________ Name of Legal Representative (if Applicant is a minor or incompetent) ______________________________________________________ Date of the Accident ________________________________________ Location _____________________________________ THE NATURE OF DISPUTE AND THE INJURES ALLEGED (attach additional sheets if necessary, although offers of settlement should not be included) ‰ Uninsured ‰ Underinsured ‰ Hit-and-Run You are hereby notified that copies of our arbitration agreement and this demand are being filed with the American Arbitration Association located at 65 Broadway, New York, NY, 10006, with a request that it commence administration of the arbitration. Please take further notice that, pursuant to § 7503 (c) of the Civil Practice Law and Rules, unless, within twenty (20) days after service of this Demand for Arbitration or Notice of Intention to Arbitrate, you apply to stay arbitration; you will thereafter be precluded from objecting that a valid agreement was not made or has not been complied with and from asserting in court the bar of a limitation of time. Signed_________________________________________________ (May be Signed by a Representative) Name, Address, Telephone and Facsimile Number of the Representative ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Telephone ( ) ________________ Fax ( ) ______________________ Name, Address, Telephone and Facsimile Number for the Applicant _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Telephone ( ) __________________ Fax ( ) ________________ American LegalNet, Inc. www.FormsWorkFlow.com DEMAND FOR ARBITRATION AMERICAN ARBITRATION ASSOCIATION The Party Making the Demand The Respondent AFFIDAVIT OF SERVICE THE STATE OF NEW YORK SS: THE COUNTY OF Being duly sworn, deposes and says that the deponent is not a party to the arbitration proceeding, is over 18 years of age, and resides at Or that, on the day of ,20 ,at No. The deponent served this demand ‰ BY REGISTERED OR CERTIFIED MAIL-RETURN RECIEPT REQUESTED by mailing a copy of the same in a securely sealed postpaid wrapper properly addressed to (the Respondent’s last known address)(the address last furnished by the Respondent) by registered or certified mail. The deponent deposited the said wrapper with the requisite postage in (an office of the U.S. Postal Service) / (an official depository under the care and custody of the U.S. Postal Service) within the State of New York. Strike inapplicable statements: a) A postmarked receipt issued by the U.S. Postal Service as proof of the mailing is attached hereto. b) Return Receipt No. is attached hereto. c) (The Respondent)(the Respondent‘s agent) designated for service refused to sign the receipt for this notice. The USPS notation of refusal is attached hereto. d) The notice was returned unclaimed. The USPS notation of nonclaimer is attached hereto. Sworn to before me this day of ,20 American LegalNet, Inc. www.FormsWorkFlow.com