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Form #791Demand for Arbitration - Accident Claims
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American Arbitration Association Accident Claim Arbitration Rules - Free Legal Form
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Printer Friendly Version
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Accident claims.
American
Arbitration Association
Accident
Claim Arbitration Rules
The original of this demand must be served
on the other party by US certified mail, return receipt requested. Three
copies, together with one copy of the parts of the policy or regulations
relating to the dispute, including the arbitration provisions, must be filed
with the AAA Regional Office at Suite 2527, 225 North Michigan Avenue, Chicago,
IL 60601-7601. The nonrefundable initial administrative fee of $200 should
accompany the initiating papers.
Demand for Arbitration
Date: _________
To the Respondent .............................................................................................................................................................................
|
(the Name of the Insurer)
|
(Send
the original to the party on whom the demand is made. When filed by an
insured, the original shall be directed to the claim 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 insured.)
|
Address ...............................................................................................................................................................................................
City and State ____________ ZIP Code ...........................................................................................................................................
Telephone (Â ) ____________
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 or hit-and-run motorists
that provides for arbitration of disputes arising thereunder in accordance with
the rules of the American Arbitration Association, hereby demands arbitration
thereunder.
The Issuing Company .......................................................................................................................................................................
Address of the Insurer Claim Office (if
Known) ..........................................................................................................................
The Name of the Individual with Whom the
Claim Was Discussed ........................................................................................
The Name of the Policyholder .........................................................................................................................................................
Address and Telephone Number of the
Policyholder .................................................................................................................
_______________
The Policy Number _________ Effective from
_________ to .......................................................................................................
The Claim File Number .....................................................................................................................................................................
Applicable Policy Limits ..................................................................................................................................................................
|
Name(s) of Claimant(s)
|
Check if a minor.
|
Amount Claimed
|
If the claimant is a minor or incompetent,
give the name of the legal representative. ......................................................
The Date of the Accident: ______ Location: ______(City
and State)
|
Type of Claim (Check one.):
|
o Uninsured Motorist
|
o Hit and Run
|
|
Â
|
o Underinsured Motorist
|
|
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 (City and State):
_______________(Give either the county of residence of the insured or the
county where the accident occurred.)
You are hereby notified that copies of our
arbitration agreement and this demand are being filed with the American
Arbitration Association at its _________ Regional Office, located at _________,
with a request that it commence administration of the arbitration.
Signed ____________(May
Be Signed by a Representative)
|
Name, Address, and
Telephone Number of the Representative:
|
Name, Address, and
Telephone Number of the Claimant:
|
|
......................................................................................................... Â
|
......................................................................................................... Â
|
|
......................................................................................................... Â
|
......................................................................................................... Â
|
|
_________ ZIP Code ...................................................................... Â
|
_________ ZIP Code ...................................................................... Â
|
|
Telephone (Â ) ______ Fax
............................................................ Â
|
Telephone (Â ) ______ Fax
............................................................ Â
|
|
o
|
|
|
Â
|
Mediation is a nonbinding process. The mediator
assists the parties in working out a solution that is acceptable to them. If
you wish for the AAA to contact the other parties to ascertain whether they
wish to mediate this matter, please check this box (there is no additional
administrative fee for this service).
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For Use in the State of
Illinois
|
Form A2l-8/94
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Submissions to this site, including any legal or business forms, posts, responses
to questions or other communications by contributors are not intended as and should
not be construed as legal advice. You are strongly encouraged to consult competent
legal council before engaging in any action based upon content contained on this
site.
These downloadable forms are only for personal use. Retransmission, redistribution,
or any other commercial use is prohibited. This includes reposting forms from this
site to another site offering free legal or other document forms for download.
Please note that the donator may have included different usage terms regarding this
form, and you agree to abide by these terms. It is highly recommended that you have
a licensed attorney review any legal documents for which you are searching in order
to make sure that your needs are being properly and completely satisfied.
Your use of this site constitutes your acceptance of our terms of use and your agreement
to hold this site, its officers, employees and any contributors to this site harmless
for any damage you might incur from your use of any submissions contained on this
site. If you do not agree to the above terms, please do not proceed.
These forms are provided to assist business owners and others in understanding important
points to consider in different transactions. They are offered with the understanding
that no legal advice, accounting, or other professional service is being offered
by these documents or on this website. Laws vary in the different states. Agreements
acceptable in one state may not be enforced the same way under the laws of another
state. Also, agreements should relate specifically to the particular facts of each
situation. Therefore, it is important to consult legal counsel whenever utilizing
these forms. The Forms are not a substitute for legal advice YourFreeLegalForms.com
is not engaged in recommending or referring members on the site or making claims
about the competence, character or qualifications of its participating members.
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Keywords: legal forms, arbitration, accident
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