Herein after known as

JOBSITE

CLAIM BY CLAIMANT

Describe the nature of the dispute, attach additional sheets as necessary:


__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Herein after known as

CLAIMANT


Herein after known as

RESPONDENT

Signature___________________________________

Date_______________________________________

Address_____________________________________ City State & Zip _____________________________

Jobsite Phone_______________________________

The parties as listed above, hereby jointly agree to Arbitrate their dispute and submit the following issue(s) to binding On-Site Arbitration pursuant to the Rules and Procedures of DMA Dispute Management & Avoidance, which shall act as tribunal.

CLAIM OR RELIEF SOUGHT BY CLAIMANT

Describe the claim (dollar amount) or remedy sought (action):


____________________________________________________________________________________________________________________________________________________________________________________________________________________

COUNTERCLAIM BY RESPONDENT

Describe the nature of the dispute, attach additional sheets as necessary:


__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

COUNTERCLAIM OR RELIEF SOUGHT BY RESPONDENT

Describe the claim (dollar amount) or remedy sought (action):


____________________________________________________________________________________________________________________________________________________________________________________________________________________

Please submit a copy of your arbitration clause, 3 copies of your entire evidence package along with this document pursuant to section 13.3 of the Rules and Procedures, the required $200 Case Manager deposit made out to: Unique Environments & mail to: 507 Knob Hill Avenue, Redondo Beach, CA 90277


Your evidence packet should include all plans, specifications, contracts, photos, documents and evidence that supports your claim.

We agree that the Arbitrators decision shall be binding. We shall abide by and perform any Award rendered hereunder and that a civil judgement may be entered upon the Award.



CLAIMANT


RESPONDENT

Name______________________________________

Address____________________________________

City, State & Zip_____________________________

Home Phone________________________________

Office Phone________________________________

Cell Phone__________________________________

Fax ________________________________________

Email_______________________________________

Signature___________________________________

Date_______________________________________

Name______________________________________

Address____________________________________

City, State & Zip_____________________________

Home Phone________________________________

Office Phone________________________________

Cell Phone__________________________________

Fax ________________________________________

Email_______________________________________

Signature___________________________________

Date_______________________________________

Signature___________________________________

Date_______________________________________