Amended Demand for Arbitration

AMENDED DEMAND FOR ARBITRATION

For adding Respondent pursuant to the No-Fault Laws of the State of New Jersey

(Effective April 1, 2011)

Date: ______Forthright File Number: ______

THE {check one box} CLAIMANT RESPONDENT

adds a new respondent to the pending arbitration as designated herein:

Amended Case Name:

______

v.

______

Claimant(s)

Name:______

Address:______

Telephone: ______Fax: ______

Email Address:______

Attorney for Claimant

Firm Name:______

Attorney Name:______

Address:______

Attorney File Number:______

Telephone: ______Fax:______

Email Address:______

Assignment of Benefits

Is the Claimant assigned benefits? No _____ Yes _____

(If yes, attach a copy of the Assignment of Benefits form)

Additional/New Respondent

Name: ______

Address:______

Telephone: ______Fax: ______

Email Address: ______

Additional/New Respondent -Insurance Claim Number(s)

Insurance Claim Number: ______

Internal Appeal Compliance

{By signing this Demand for Arbitration the filer certifies to the accuracy of the Internal Appeal Compliance information below. Failure to provide this information will result in the Demand for Arbitration to be administratively deficient and case will not be initiated.}

I certify that the Respondent:

Does require an Internal Appeal prior to the filing of this Demand for Arbitration, that the claimant complied with Respondent’s internal appeal process and the claimant has attached hereto the submitted Pre-Service and/or Post-Service Appeal forms.

Does Not Require an Internal Appeal prior to the filing of this Demand for Arbitration.

Additional/New Respondent Policy Information

Name of Policyholder: ______

Address: ______

Policy Number (if known):______

Attorney for Additional/New Respondent (if known)

Firm Name: ______

Name: ______

Address:______

Attorney File Number: ______

Telephone: ______Fax: ______

Email Address: ______

ORIGINAL RESPONDENT INFORMATION

Withdrawal of Original Respondent

(Check ONLY if requesting a withdrawal of the original respondent)

I am requesting a withdrawal of the original Respondent listed below.

Original Respondent -Insurance Claim Number(s)

Insurance Claim Number: ______

Original Respondent

Name: ______

Address:______

Telephone: ______Fax: ______

Email Address: ______

Last known Claim's Representative: ______

Injured Person(s)

Name:______

Address: ______

Accident Information

Date: ______State in which the accident occurred:______

Nature of Dispute: ______

______

Claims Submitted

(Check all applicable claims)

Medical Expense Benefits {Consult Rule 7, ¶ 11 for calculation of amount claimed. Attach copies of all invoices in dispute}

Name of Date(s) of Date Claim Amount Claimed

Provider Service Submitted to

Insurer

______

______

______

Total Medical Expense Benefits Claimed $______

Death Benefits (Amount with explanation and calculation)

$______

Essential Services Benefits (Amount with explanation and calculation)

$______

Funeral Expenses (Amount with explanation and calculation)

$______

Income Continuation (Amount with explanation and calculation)

$____________

Total Personal Injury Protection Benefits Claimed: $______

Interest (Amount with explanation and calculation)

$______

Attorney’s Fees (Amount with explanation and calculation)

$______

Costs of Arbitration (Amount with explanation and calculation)

$______

Certification of Service and No Other Actions

I CERTIFY that I have served a true and complete copy of this Demand for Arbitration with copies of all attachments upon the respondent(s) as required by the Rules. To the best of my knowledge, there are no other actions pending in any court or arbitration proceedings that arise out of treatment to the same injured person(s), that arise out of the same accident, or that should otherwise be joined in this arbitration except as follows:

______

______

______

Signature of Attorney or Claimant

Filing Instructions

Please send ONLY the original Demand and ONE copy of all attachments, along with the administrative fee of $225 to:

Forthright

285 Davidson Avenue, Suite 502

Somerset, New Jersey 08873

Methods of Payment

Check in the amount of $______payable to Forthright enclosed.

Please charge my credit card on file with Forthright for $______. {If your credit card information is not on file, please contact Forthright at 732.271.6127 to provide it}

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