Notice of Request to Arbitrate - Yukon Dispute Resolution Board

This Form Constitutes the Official Request to Arbitration under the DRB Arbitration Rules

Notice of Request to Arbitrate

Date *

Claimant filing the Notice of Request to Arbitrate *

Organization

Address *

Phone *

Fax

Email *

Claimant's Counsel *

Organization

Address *

Phone *

Fax

Email *

Respondent - 1 *

Organization

Address *

Phone *

Fax

Email *

Respondent's Counsel *

Organization

Address *

Phone *

Fax

Email *

Respondent - 2 (if applicable)

Organization

Address

Phone

Fax

Respondent's Counsel

Organization

Address

Phone

Fax

Respondent - 3 (if applicable)

Organization

Address

Phone

Fax

Respondent's Counsel

Organization

Address

Phone

Fax

1. Provide a Brief Description of the Matters in Dispute or a Statement of Claim including the name of the Final Agreement(s) and the section(s): *

2. Where compensation is claimed, provide an estimate of amount claimed or the value of the issue in dispute:

3. Where the value cannot be estimated provide an explanation of the reason:

4. Provide a statement of what remedy the claimant is seeking:

5. State whether the parties have agreed to the Tribunal being comprised of: *

one arbitrator

three arbitrators

have not yet agreed

6. Provide the name(s) of any agreed upon Arbitrator(s):

7. Provide the agreed upon qualifications of the Arbitrator(s):

8. Request for appointment of Arbitrator(s) by the Dispute Resolution Board: *

Yes

State number of requested tribunal arbitrators:

one

three

9. Provide a statement of any variations or exclusions of the Rules to which the parties have agreed to in writing:

Please append the following: a) A statement of the specific provision of a Settlement Agreement or Settlement Legislation under which the dispute is referred to arbitration

b) A copy of any agreement between the parties to refer a dispute to arbitration

c) A copy of any contract related to the dispute

Signature *

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