Arbitration Forums, Inc

Effective February 1, 2010AUTOMOBILE SUBROGATION ARBITRATION FORUM

Member Service Department

P. O. Box 30174

Tampa, FL 33630-3174

Phone: 1-866-977-3434

Overnight Mail:

3450 Buschwood Park Drive

Suite 250

Tampa, FL 33618

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This is a BINDING arbitration. Nonmembers answering are bound by this decision.

Check if Amendment (Highlight Amended Area)

Complete if you are a Third Party Administrator (TPA): TPA Code TPA Name

I. APPLICANT INFORMATION and ALLEGATIONS (Rule 2-1)

Company Code Billing Code

Company/Subsidiary Name

Representative

Rep. Address

Telephone Number () ext.

Fax Number ()

E-Mail (Required)

Insured Name

File Number

Date of Loss

City State

LOCATION OF ACCIDENT

Total Company Claim Amount$

Deductible Paid By Insured $

Payments Accepted$

Legal Fees $

I will accept policy limits (Article Second (d)).

I request one-year deferment (Rule 2-10).

I request Notice of Hearing (Rule 3-1).

I request a three-person panel (Rule 3-3).

Appearance will be made by:(Rule 3-7).

Member Representative Insured ExpertWitness

CERTIFICATION OF SERVICE: The Applicant certifies that requirements of Rule 2-1, and condition precedent have been fulfilled.

______

SignatureDate:

II. RESPONDENT INFORMATION and ALLEGATIONS (Rule 2-2)

RESPONDENT # and COMPANY CODE

BILLING CODE

RESPONDENT #1

Subsidiary Name

Rep. Name

Rep. Address

File #

Insured

RESPONDENT #2

Subsidiary Name

Rep. Name

Rep. Address

File #

Insured

RESPONDENT #3

Subsidiary Name

Rep. Name

Rep. Address

File #

Insured

Yes No A liability policy was in effect at the time of loss

Yes No Coverage has been denied for this claim (Rule 2-4)

If yes, a copy of the denial letter to the party seeking coverage must be attached.

I admit % liability? Liability Deductible: $

Amount Paid to Applicant Company: $

Deductible Amount Paid To Applicant’s Insured: $

I request one-year deferment (Rule 2-10).

I request three-person panel (Rule 3-3).

Appearance will be made by: (Rule 3-7).

Member Representative Insured ExpertWitness

COMPLETE THE FOLLOWING TO FILE A COUNTERCLAIM

Total Company Claim Amount: $

Deductible Paid By Insured: $

Payments Accepted:$

Legal Fees:$

I will accept policy limits (Article Second (d)).

CERTIFICATION OF SERVICE: The Respondent certifies that requirements of Rule 2-2, and condition precedent have been fulfilled.

______

SignatureDate

Telephone Number () ext.

Fax Number ()

E-Mail (Required)

Arbitration Forums, Inc.

Contentions Sheet

(Required per Rules)

File provided by:(check one)Applicant or Respondent #

(Identify yourself below)

Company Name:

Insured:File #:

APPLICANT AFFIRMATIVE PLEADINGS: (Rule 2-4)

RESPONDENT AFFIRMATIVE DEFENSES: (Rule 2-4)

If you raise a Policy Limit affirmative defense, include the policy limit amount along with your affirmative defense description.

DEFERMENT JUSTIFICATION: (Rule 2-10)

CONTENTIONS:

EVIDENCE:

List evidence which will support contentions stated above (i.e., police report, damages, estimates, statements). Photocopies of evidence are suggested. Photos will not be returned without a sufficient size self-addressed envelope with adequate postage. Note this request in theAdministrative Request section below.

10.

11.

12.

APPLICANT ITEMIZED COMPANY-PAID DAMAGES:

Filing company: itemize payments made to support your Total Company Claim Amount. The Total Itemized Company-Paid Damages must match your Total Company Claim Amount.

Total Itemized Company-Paid Damages:

RESPONDENT DISPUTED DAMAGES: (Rule 2-5)

Responding company (or applicant filing with automatic counter response): Present your damages arguments and outline the amount of damages in dispute. If left blank, damages will not be considered at issue.

Administrative Requests: