PENSION PLAN CLAIMS REQUEST FOR ARBITRATION Multiemployer Pension Plan Arbitration Rules for Withdrawal Liability Disputes Date: Name of Employer: Name of Employer's Representative: Check applicable box: Filing Party is Contact Person: Address: City: Telephone: Email Address: Employer Pension Fund Name of Firm (if applicable): Representative's Address: State: Zip Code: City: Telephone: Email Address: AAA should communicate with me by: Email Mail State: Zip Code: Additional Email(s) to be copied on correspondence: Arbitration is demanded pursuant to the terms of the Plan, which provides for arbitration under the of the AAA's Multiemployer Pension Plan Arbitration Rules for Withdrawal Liability Disputes. The named parties hereby submit the dispute for arbitration under the AAA's Multiemployer Pension Plan Arbitration Rules for Withdrawal Liability Disputes. Nature of Dispute: Dollar Amount of Claim: $ Other Relief Sought: Attorneys Fees Punitive/Exemplary Amount Enclosed: $ In accordance with Fee Schedule: Interest Other Standard Fee Schedule Arbitration Costs Flexible Fee Schedule Please describe appropriate qualifications for arbitrator(s) to be appointed to hear this dispute: The filing party requests that hearings be held at the following location: Check one: Agreement of the Parties Locale Provision specified in the Plan You are hereby notified that copies of our arbitration agreement and this demand are being filed with the American Arbitration Association office located in , with a request that it commence administration of the arbitration. Under the rules, you may file an answering statement within seven (7) days after notice from the AAA. Name of Pension Fund: Name of Pension Fund's Representative: Contact Person: Address: City: Telephone: Email Address: State: Zip Code: Name of Firm (if applicable): Representative's Address: City: Telephone: Email Address: AAA Customer Service can be reached at 800.778.7879. State: Zip Code: Reminders: Send a copy of this form to the other side at the time it is forwarded to the AAA. Please reference appropriate fees pursuant to the fee schedule outlined in the Rules. You can file your case online by visiting the AAA's website at www.adr.org. Please select "AAA WebFile" from the list of side menu options. You may also wish to visit our website for a complete list of our administrative services and procedures. Your case manager can also provide additional information. American LegalNet, Inc. www.FormsWorkFlow.com