Official Federal Forms > American Arbitration Association > Government And Consumer
North Carolina Disaster Mediation Program Request Form - Official Federal Forms
| North Carolina Disaster Mediation Program Request Form Form. This is a national form and can be used in Government And Consumer American Arbitration Association . |
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American Arbitration Association Mediation Request Form 1.Name of Homeowner (Please Print): 2. Address and County of the damaged property/claim: Street City State Current Address: Street City State Your Phone Number (with Area Code): Zip County Zip Your Email Address: 3. Full Name of Insurance Company (as it appears on policy): Address of Insurance Company: Street City State Zip Insurance Co. Email: Insurance Co. Contact Person: Your Policy Number: Insurance Co. Phone (with Area Code): Insurance Co. Fax (with Area Code): 4. Your Claim Number: 5. Date on which You Received Denial Notice: 6. BRIEF DESCRIPTION OF THE DISPUTE, including amount(s) disputed (Attach additional sheet if necessary): Please Note: To speed up the process, please complete and return this form ONLY. Please bring any additional paperwork to the mediation conference. · · · Have you commenced the appeals/appraisal process under your policy? If yes, have you completed the appeals/appraisal process? Have you filed any legal action with regard to this claim? Yes Yes Yes No No No YOUR SIGNATURE: DATE: IMPORTANT NOTICE: Your claim might be eligible for mediation pursuant to North Carolina General Statute 58-44-70 (Senate Bill 277, Session Law 2006-145), which established a Mediation Program to facilitate the effective, fair, and timely handling of disputed residential property damage claims arising out of declared disasters. To be eligible for the Program, the amount of the dispute (the difference between the parties) must be at least $1,500, unless both parties agree to mediate a smaller claim. The program does not apply to claims denied due to policy exclusions, policy terms/provisions, or policy not being in effect on the date of loss. Also, the program does not apply to commercial insurance, private passenger motor vehicle insurance or National Flood Insurance Program flood policies. All program costs are paid by the insurer. Complete this form and return it to: American Arbitration Association Center for Mediation ATTN: NC Disaster Mediation 13455 Noel Road, Suite 1750 Dallas, TX 75240 or Fax to: 855.267.4082 or Email to NCDisasterMediation@adr.org Resources: American Arbitration Association's website: http://www.adr.org/northcarolinadisaster Your insurance company adjustor or customer service department. Your insurance agent. The consumer information page on the NC Department of Insurance website: www.ncdoi.com American LegalNet, Inc. www.FormsWorkFlow.com
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