Fill and Sign the Arbitration Case Form

US-0011GB Arbitration Case Submission FormPage 1 of 2 Arbitration Case Submission Form This Arbitration Case Submission Form (this Submission Form ) is made this day of , 20 , by and between , (Name of Claimant) hereinafter called the Claimant and , hereinafter called the (Name of Respondent) Respondent. Claimant and Respondent are collectively referred to as the Parties. Whereas, a dispute has arisen between the Parties which is not in litigation, but as to which the Parties have agreed to pursue binding Arbitration; and Whereas, the Parties have agreed to resolve the Litigation by submitting to binding arbitration in accordance with this Agreement. Now, therefore, for and in consideration of the mutual covenants contained in this Agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the Parties enter into the following Submission Form: Full Name of Claimant Counsel for Claimant’s Full Name Street Address of Counsel for Claimant State, City and Zip Code of Counsel for Claimant Telephone Number of Counsel for Claimant Fax No. of Counsel of Claimant E-mail of Counsel of Claimant Full Name of Respondent Full Name of Counsel for Respondent Street Address of Counsel for Respondent US-0011GB Arbitration Case Submission FormPage 2 of 2 State, City and Zip Code of Counsel for Respondent Telephone Number of Counsel for Respondent Fax No. of Counsel of Respondent E-mail of Counsel of Respondent Case Information: Case Type: Personal injury, Business, Contract, Collection, Employment, Real Property Other Have the parties signed an agreement containing an arbitration clause? Yes No Have all parties consented to arbitration? Yes No Has the arbitrator been selected? Yes No If yes, who has been selected? Is this Consumer Arbitration? Yes No If yes, please see the Consumer Arbitration Rules for further information. Parties have agreed to share equally the necessary expenses in connection with the arbitration including compensation to in an amount not (Name of Arbitrator) more than . (Dollar Amount)