<p> AMENDED DEMAND FOR ARBITRATION For adding Respondent pursuant to the No-Fault Laws of the State of New Jersey (Effective April 1, 2011)</p><p>Date: ______Forthright File Number: ______</p><p>THE {check one box} CLAIMANT RESPONDENT adds a new respondent to the pending arbitration as designated herein: </p><p>Amended Case Name:</p><p>______v.</p><p>______</p><p>Claimant(s) Name:______</p><p>Address:______</p><p>Telephone: ______Fax: ______</p><p>Email Address:______</p><p>Attorney for Claimant Firm Name:______</p><p>Attorney Name:______</p><p>Address:______</p><p>Attorney File Number:______</p><p>Telephone: ______Fax:______</p><p>Email Address:______</p><p>Assignment of Benefits Is the Claimant assigned benefits? No _____ Yes _____ (If yes, attach a copy of the Assignment of Benefits form)</p><p>1 Additional/New Respondent Name: ______</p><p>Address:______</p><p>Telephone: ______Fax: ______</p><p>Email Address: ______</p><p>Additional/New Respondent -Insurance Claim Number(s)</p><p>Insurance Claim Number: ______</p><p>Additional/New Respondent Policy Information</p><p>Name of Policyholder: ______</p><p>Address: ______</p><p>Policy Number (if known):______</p><p>Attorney for Additional/New Respondent ( if known )</p><p>Firm Name: ______</p><p>Name: ______</p><p>Address:______</p><p>Attorney File Number: ______</p><p>Telephone: ______Fax: ______</p><p>Email Address: ______</p><p>ORIGINAL RESPONDENT INFORMATION</p><p>Withdrawal of Original Respondent (Check ONLY if requesting a withdrawal of the original respondent)</p><p>I am requesting a withdrawal of the original Respondent listed below.</p><p>Original Respondent -Insurance Claim Number(s)</p><p>Insurance Claim Number: ______</p><p>Original Respondent Name: ______</p><p>2 Address:______</p><p>Telephone: ______Fax: ______</p><p>Email Address: ______</p><p>Last known Claim's Representative: ______</p><p>Injured Person(s) Name:______</p><p>Address: ______</p><p>Accident Information</p><p>Date: ______State in which the accident occurred:______</p><p>Nature of Dispute: ______</p><p>______</p><p>______</p><p>Claims Submitted (Check all applicable claims)</p><p>Medical Expense Benefits {Consult Rule 7, ¶ 11 for calculation of amount claimed. Attach copies of all invoices in dispute}</p><p>Name of Date(s) of Date Claim Amount Claimed Provider Service Submitted to Insurer ______</p><p>______</p><p>______</p><p>Total Medical Expense Benefits Claimed $______</p><p>Death Benefits (Amount with explanation and calculation)</p><p>$______</p><p>Essential Services Benefits (Amount with explanation and calculation)</p><p>$______</p><p>3 Funeral Expenses (Amount with explanation and calculation)</p><p>$______</p><p>Income Continuation (Amount with explanation and calculation)</p><p>$______</p><p>Total Personal Injury Protection Benefits Claimed: $______</p><p>Interest (Amount with explanation and calculation)</p><p>$______</p><p>Attorney’s Fees (Amount with explanation and calculation)</p><p>$______</p><p>Costs of Arbitration (Amount with explanation and calculation)</p><p>$______</p><p>Certification of Service and No Other Actions</p><p>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: </p><p>______</p><p>______</p><p>______Signature of Attorney or Claimant</p><p>Filing Instructions</p><p>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</p><p>4 Somerset, New Jersey 08873</p><p>Methods of Payment</p><p>Check in the amount of $______payable to Forthright enclosed.</p><p>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}</p><p>5</p>