Ubisoft, Inc.
Consumer Demand for Arbitration before the
American Arbitration Association

Instructions on filing a claim:

1. To file a consumer-related claim, please fill out this form and retain one copy for your records. By filling out this form, you are requesting an arbitration as a consumer of Ubisoft, Inc. products or services.

2. Mail a copy of this form and your check or money order made payable to the American Arbitration Association to AAA’s Case Filing Services, 1101 Laurel Oak Road, Suite 100, Voorhees, NJ 08043. Please consult Section C-8 of the Supplementary Procedures for Consumer-Related Disputes for the appropriate fee. Information regarding the nearest Case Management Center and the appropriate fee is available at www.adr.org or by calling AAA Customer Service at (800) 778-7879.

3. Send a copy of this form and a copy of the check or money order to Ubisoft, Inc. 300 Mission Street, 20th Floor, San Francisco, CA 94105

4. Send a copy of the arbitration agreement or arbitration provision from the applicable agreement to AAA.

5. Please complete the following information:

(1) Briefly explain the nature of the dispute:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

(2) Do you believe there is any money owed to you? [ ] No.[ ] Yes.

If yes, how much? ___________________.

(3) Are you requesting a non-monetary outcome? [ ] No.[ ] Yes.

If yes, what is it? ________________________________________________________

(4) If an in-person hearing is held, the arbitration will take place in Chicago, Illinois.

(5) Amount enclosed for Arbitration fee: ___________________.

(6) Please fill out the following information:

Consumer Information

Consumer’s Name ________________________________

Address ________________________________________

City/State/Zip ___________________________________

Telephone ______________________________________

Fax ____________________________________________

Signature of Consumer ____________________________

If you have an Attorney, your Attorney’s information (please leave blank if you are representing yourself)

Name ________________________________________

Firm _________________________________________

Address ______________________________________

City/State/Zip__________________________________

Telephone ____________________________________

Fax __________________________________________

Email Address__________________________________

CH92116.1
216054-10002