FILED: NASSAU COUNTY CLERK 10/21/2024 05:04 PM
`NYSCEF DOC. NO. 6
`
`INDEX NO. 618570/2024
`
`RECEIVED NYSCEF: 10/21/2024
`
`"C"
`
`Exhibit
`
`

`

`7 Pages via SFTP Thu, 10 Oct 2024 03:16:25 GMT
`
`FILED: NASSAU COUNTY CLERK 10/21/2024 05:04 PM
`NYSCEF DOC. NO. 6
`
`INDEX NO. 618570/2024
`
`RECEIVED NYSCEF: 10/21/2024
`
`
`
`
`
`AMERICAN ARBITRATION ASSOCIATION”
`
`AMERICAN ARBITRATION ASSOCIATION
`NEW YORK STATE SUM/UM
`ARBITRATION TRIBUNALS
`
`The original of this dernand must be served on the other party by of U.S. certified mail-return receipt requested. Three (3) copies of this
`dernand, together with corresponding copies of the endorsement and declarations page, must be filed at 32 Old Slip, 33° Floor,
`New York, NY 10005. A non-refundable administrative fee in the amount of two hundred and fifty dollars ($250) is due and payable at the
`time of filing this demand.
`
`REQUEST FOR CL] SUM ARBITRATION OR [UM ARBITRATION
`Choose One Only
`
`(choice of forum for resolution of the dispute is subject to the information contained in the declarations sheet, if provided)
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`PLEASE TAKE NOTICE that the filing party, a party to an insurance policy providing tor protection against loss due to personal
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`City: Clinton
`Zip Code: 52733
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`Name of the Individual with Whom the Claim was Discussed:
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`Name of the POlcynOnser. Migue Rodriguez _
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`| Address and Telephone Number of the Policyholder: (on date of accident) _
`122 N. Wainut Street
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`City: Massapequa
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`State: New York
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`| Zip Code: 11758
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`Name(s) of Applicani(s):
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`: Miguel Rodriguez
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`Page 1 of 3
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`ECN: 2024100802305
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`
`
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`Received Date: 2024-10-08
`
`

`

`7 Pages via SFTP Thu, 10 Oct 2024 03:16:25 GMT
`
`FILED: NASSAU COUNTY CLERK 10/21/2024 05:04 PM
`NYSCEF DOC. NO. 6
`
`INDEX NO. 618570/2024
`
`RECEIVED NYSCEF: 10/21/2024
`
`
`
`
`AMERICAN ARBITRATION ASSOCIATION”
`
`AMERICAN ARBITRATION ASSOCIATION
`NEW YORK STATE SUM/UM
`ARBITRATION TRIBUNALS
`
`|
`t i Name ot Legal Representative: (if Applicant is a minor or incompetent)
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`Date of the Accident: 11/17/2023
`
`: _ Location: Merrick Blvd at or near 218 street, Queens, NY
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`‘The Nature of Dispute and the injures Alleged:
`(attach additional sheets if necessary, although offers of settlement should not be included)
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`¥} Uninsured ( Underinsured ( Hit-and-Run
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`You are hereby notified that copies of our arbitration agreement and this demand are being filed with the American Arbitration Association
`located at 32 Old Slip, 33rd Floor, New York, NY 10005, with a request that it commence administration of the arbitration.
`
`Please take further notice that, oursuant to § 7503. (c) of the Civil Practice Law and Rules, unless, within twenty (20) days after service of this
`Demand for Arbitration or Notice of Intention to Arbitrate, you apply to stay arbitration; you will thereafter be precluded from objecting
`that a valid agreement was not made or has not been complied with and freth/assertiag in court the bar of a limitation of time.
`
`Signed (may be signed by a representative):
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`| Representative: s Address: 2284 Babylon Turnpike
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`ECN: 2024100802305
`
`Received Date: 2024- 10- 08
`
`
`
`

`

`7 Pages via SFTP Thu, 10 Oct 2024 03:16:25 GMT
`
`FILED: NASSAU COUNTY CLERK 10/21/2024 05:04 PM
`NYSCEF DOC. NO. 6
`
`INDEX NO. 618570/2024
`
`RECEIVED NYSCEF: 10/21/2024
`
`
`
`AMERICAN ARBITRATION ASSOCIATION
`
`DEMAND FOR ARBITRATION
`AMERICAN ARBITRATION ASSOCIATION
`
`
`
`
`
`
`
`The Party Making the Demand
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`The Respondent
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`THE STATE OF NEW YORK
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`says that the deponent is not a party to the arbitration proceeding, is over 18 years of age,
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`Or that, on the
`
`4 day of , [bbe
`
`20,LY at No.
`
`The deponent served this demand
`
`dey REGISTERED OR CERTIFIED MAIL-RETURN RECIEPT REQUESTED
`
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`by mailing a copy of the same in a securely sealed postpaid wrapper properly addressed to: Ab, - 2990
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`(the Respondent's last known address)(the address last furnished by the Respondent) by registered or certified mail. The
`deponent deposited the said wrapper with the requisite postage in (an oftice of the U.S. Postal Service) / (an official
`depository under the care and custody of the U.S. Postal Service) within the State of New York.
`
`Strike inapplicable statements:
`
`a)
`
`b)
`
`c)
`
`A postmarked receipt issued by the U.S. Postal Service as proof of the mailing is attached hereto.
`
`Return Receipt No.
`
`is attached hereto.
`
`(The Respondent}(the Respondent's agent) designated for service refused to sign the receipt for this notice.
`The USPS notation of refusal is attached hereto.
`
`ad)
`
`The notice was returned unclaimed. The USPS notation of nonclaimer is attached hereto.
`
`Sworn to before me this
`
`
`
`
`
`July 8, 2024
`
`INOTARY PUBLIC, STATE OF NEW YORK
`Registration No. 02AL6394384
`Qualified in Suffolk County
`Commission Expires
`
`|
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`Page 3 of 3
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`
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`ECN: 2024100802305
`
`
`
`
`
`
`Received Date: 2024-10-08
`
`