Effective February 1, 2010 PROPERTY SUBROGATION ARBITRATION FORUM (P-FORM)
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
Property-Form
This is a BINDING arbitration. Nonmembers answering are bound by this decision.
Check if Amendment (Highlight Amended Area)
I. APPLICANT INFORMATION and ALLEGATIONS (Rule 2-1)
P-Form 2/10 © 2010 Arbitration Forums, Inc. TVB
Company Code Billing Code
Company/Subsidiary Name
Representative
Rep. Address
Telephone Number ( ) ext.
Fax Number ( )
E-Mail Address
Insured Name
File Number
Date of Loss
City State
LOCATION OF ACCIDENT
Company Claim Amount ACV RCV
Insured Deductible
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 Expert Witness
CERTIFICATION OF SERVICE: The Applicant certifies that requirements of Rule 2-1, and condition precedent have been fulfilled.
______________________________________________
Signature Date:
II. RESPONDENT INFORMATION and ALLEGATIONS (Rule 2-2)
P-Form 2/10 © 2010 Arbitration Forums, Inc. TVB
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
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 Expert Witness
COMPLETE THE FOLLOWING TO FILE A COUNTERCLAIM
Yes, I would like to file a Counterclaim (Rule 2-2)
Company Claim Amount (ACV RCV)
Insured Deductible
Legal Fees
CERTIFICATION OF SERVICE: The Respondent certifies that requirements of Rule 2-2, and condition precedent have been fulfilled.
______________________________________________
Signature Date
Telephone Number ( ) ext.
Fax Number ( )
E-Mail Address
P-Form 2/10 © 2010 Arbitration Forums, Inc. TVB
Arbitration Forums, Inc.
Contentions Sheet
(Required per Rules)
File provided by:(check one) Applicant or Respondent #
Special/ Uninsured Motorists’ Company #1or Company #
(Identify yourself below)
Company Name:
Insured: File #:
AFFIRMATIVE DEFENSES/PLEADINGS: (Rule 2-4)
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 the Administrative Request section below.
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DAMAGES:
Filing company: itemize payments made to support your claim amount. Responding company: Present your damages arguments and outline the amount of damages in dispute. If left blank, damages will not be considered at issue (Rule 2-5).
Administrative Requests:
P-Form 2/10 © 2010 Arbitration Forums, Inc. TVB