Pursuant to the No-Fault Laws of the State of New Jersey

DEMAND FOR ARBITRATION

Pursuant to the No-Fault Laws of the State of New Jersey

(effective January 1, 2008)

Date: ______Web Username: ______

THE CLAIMANT herein demands dispute resolution of certain Personal Injury Protection Benefits pursuant to a policy of insurance issued by the named respondent(s) and in accordance with the Rules for No Fault Arbitrations in the State of New Jersey.

Case Name:

______

v.

______

Injured Person(s)

Name :______

Address: ______

Claimant(s)

Name: ______

Address: ______

Attorney for Claimant

Firm Name: ______

Name: ______

Address: ______

Attorney File Number: ______

Telephone: ______Fax: ______

Email Address: ______

Policy Information*

Name of Policyholder: ______

Address: ______

Policy Number (if known) :______

Insurance Claim Number(s)*

Insurance Claim Number: ______

Respondent*

Name: ______

Address: ______

Telephone: ______Fax (if known):______

Attorney forRespondent (if known)*

Firm Name: ______

Name: ______

Address: ______

Attorney File Number: ______

Telephone: ______Fax: ______

Email Address: ______

{* please include the above information for each named respondent}

Accident Information

Date: ______State in which the accident occurred:______

Assignment of Benefits

Is the Claimant assigned benefits?No _____ Yes _____

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

Nature of Dispute: ______

______

Emergent/Expedited Relief

(Check ONLY if requesting Emergent/Expedited Relief)

Emergent/Expedited Relief (Refer to the Rule 9 for additional filing requirements and include the Emergent/Expeditedapplication fee).

Claims Submitted

(Check all applicable claims)

Medical Expense Benefits {Exact amounts claimed and details thereof to the extent known. Attach copies of all invoices in dispute}

Name ofDate(s) ofDate ClaimAmount Claimed

ProviderTreatmentSubmitted to

Insurer

______

______

______

______

Total Medical Expense Benefits Claimed $______

Interest (Amount with explanation and calculation)

$______

Attorney’s Fees (Amount with explanation and calculation)

$______

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)

$______

Costs of Arbitration (Amount with explanation and calculation)

$______

Hearing Region

Arbitration Hearing Region: North _____ Central _____ South _____

Certification of Service and No Other Actions

I CERTIFY that I have served a true and complete copy of this Demand for Arbitrationwith 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:

National Arbitration Forum

285 Davidson Avenue, Suite 502

Somerset, New Jersey08873

Methods of Payment

Check in the amount of $______payable to National Arbitration Forum enclosed.

Please charge my credit card for $______.

Credit Card Information

Ple My credit card information is on file with the National Arbitration Forum.

or

Visa Card: ______

MasterCard: ______

American Express: ______

Expiration Date: ______

Signature: ______

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