MEMORANDUM OF UNDERSTANDING

Reference to Ascertain Amount of Loss In a Fire Insurance Claim Accordance with M.G.L. c. 175, §§ 99 through 100H

This Memorandum of Understanding (“Memorandum”) is entered into by and among the Massachusetts Division of Insurance (“Division”), [Name of Insurance Company], [Name of Insured] and [Name of Third Referee Appointed by Division] (collectively the “Parties”) for the purposes of ascertaining the amount of loss in claim presented under a standard policy of fire insurance set forth in M.G.L. c. 175, § 99 in accordance with M.G.L. c. 175, §§ 99 through 100H.

The Parties additionally agree as follows:

1. On [date of notice], [Name of Insured] notified [Name of Insurance Company] of a fire loss and submitted a claim accompanied by a sworn statement in proof of loss in accordance with M.G.L. c. 175, § 99. [Name of Insured] and [Name of Insurance Company] disagree as to the amount of the loss.

2. On [date of notice], [Name of Insured] made a written demand for reference to [Name of Insurance Company] for a determination of the amount of the loss in accordance with M.G.L. c. 175, § 100.

[If referee selected by Insured has not served as referee for either party in prior 4 months]

3. The referee selected by [Name of Insured] in accordance with M.G.L. c. 175, § 100 is [Name and Address of referee selected by Insured]. This referee is a disinterested person, a resident of the Commonwealth, willing to act in this capacity and has not served as referee for either party within four months prior to the date of nomination as set forth in M.G.L. c. 175, § 100B.

[If referee selected by Insured has served as referee for either party in prior 4 months]

3. The referee selected by [Name of Insured] in accordance with M.G.L. c. 175, § 100 is [Name and Address of referee selected by Insured]. This referee is a disinterested person, a resident of the Commonwealth and willing to act in this capacity as set forth in M.G.L. c. 175, § 100B. Although [Name of Referee selected by Insured] has served as a referee for [Name of Insured or Insurance Company] within four months prior to nomination in this reference proceeding, [Name of Insurance Company] has provided written consent to [Name of Insured] to have [Name of referee selected by Insured] serve as referee in this reference proceeding.

[If referee selected by Insurance Company has not served as referee for either party in prior 4 months]

4. The referee selected by [Name of Insurance Company] in accordance with M.G.L. c. 175, § 100 is [Name and Address of referee selected by Insurance Company]. This referee is a disinterested person, a resident of the Commonwealth, willing to act in this capacity and has not served as referee for either party within four months prior to the date of nomination, as set forth in M.G.L. c. 175, § 100B.

[If referee selected by Insurance Company has served as referee for either party in prior 4 months]

4. The referee selected by [Name of Insurance Company] in accordance with M.G.L. c. 175, § 100 is [Name and Address of referee selected by Insurance Company]. This referee is a disinterested person, a resident of the Commonwealth and willing to act in this capacity as set forth in M.G.L. c. 175, § 100B. Although [Name of Referee selected by Insurance Company] has served as a referee for [Name of Insured or Insurance Company] within four months prior to nomination in this reference proceeding, [Name of Insured] has provided written consent to [Name of Insurance Company] to have [Name of referee selected by Insurance Company] serve as referee in this reference proceeding.

5. The selected referees, [Name and Address of referee selected by Insurance Company] and [Name and Address of referee selected by Insured] are unable to agree upon and select a third referee and, in accordance with M.G.L. c. 175, § 100, [Name of referee applying for reference] have applied to the Commissioner of Insurance (“Commissioner”) for the appointment of a third referee.

[If referee appointed by Commissioner has not served as referee for either party in prior 4 months]

6. The Commissioner has appointed [Name of and Address of Third Referee] to serve as the third referee of this reference proceeding in accordance with M.G.L. c. 175, § 100. This third referee is a disinterested person, a resident of the Commonwealth, willing to act in this capacity and has not served as referee for either party within four months prior to the date of appointment, as set forth in M.G.L. c. 175, § 100B.

[If referee appointed by Commissioner has served as referee for either party in prior 4 months] 6.

The Commissioner has appointed [Name and Address of Third Referee] to serve as the third referee of this reference proceedings in accordance with M.G.L. c. 175, § 100. This third referee is a disinterested person, a resident of the Commonwealth and willing to act in this capacity as set forth in M.G.L. c. 175, § 100B. Although [Name of Third Referee] has served as a referee for [Name of Insured or Insurance Company] within four months prior to nomination in this reference proceeding, both [Name of Insured] and [Name of Insurance Company] have provided written consent to the Commissioner to have [Name of Third Referee] serve as third referee in this reference proceeding. [Name of Third Referee] has not been previously nominated by either party in connection with this reference proceeding.

7. The Commissioner has notified the third referee and the parties in writing of the appointment of [Name of Third Referee] to serve as the third referee of this reference proceeding in accordance with M.G.L. c. 175, § 100.

8. Within ten (10) days of the Commissioner’s appointment of the third referee, the three referees shall meet to hear evidence in the case. The hearing may adjourn from time to time, but not more than one week shall elapse between hearings except by unanimous agreement by the referees. The referees shall reduce their award to writing and issue a signed, written decision, in duplicate, on the amount of loss, which shall be delivered to [Name of Insurance Company] and [Name of Insured] by the third referee. The third referee also shall deliver a copy of the decision to the Commissioner. The decision of a majority of the referees shall be conclusive and final upon [Name of Insurance Company] and [Name of Insured] in accordance with M.G.L. c. 175, §§ 99 and 101B.

9. If the policy contains a reduced rate or co-insurance clause and the parties do not agree on the sound value of the affected property, the referees shall determine the sound value of the property as set forth in M.G.L. c. 175, § 101D.

10. [Name of Third Referee] will examine any agreement for reference that may have been made by the insured and the [Name of Insurance Company]’s representative to see that the terms of such agreement are fulfilled. The referees are not required to sign any agreement that would be detrimental to either party relating to their respective interests.

11. [Name of Insurance Company] and [Name of Insured] shall each be liable for the payment of the reasonable charges and expenses of their respective referees.

12. If an award is rendered in favor of [Name of Insured], both [Name of Insurance Company] and [Name of Insured] shall each be liable for one half of the compensation and reasonable charges and expenses of [Name of Third Referee] in accordance with M.G.L. c. 175, § 101B. In such case, [Name of Third Referee] shall furnish [Name of Insurance Company] and [Name of Insured] with a written statement specifying in detail his or her charges for compensation and expenses. Such statement shall be in accordance with the hourly rates for [Name of Third Referee] currently on file with the Division, specifically [list applicable hourly fees and expenses].

13. If an award is rendered in favor of [Name of Insurance Company], or if no award is rendered, [Name of Insurance Company] shall be liable for the full amount of the compensation and reasonable charges and expenses of [Name of Third Referee] in accordance with M.G.L. c. 175, § 101B. In such case, [Name of Third Referee] shall furnish the company alone with a written statement specifying in detail his or her charges for compensation and expenses. Such statement shall be in accordance with the hourly rates for [Name of Third Referee] currently on file with the Division, specifically [list applicable hourly fees and expenses]. If [Name of Insurance Company] makes any payment to [Name of Insured] to settle the claim, [Name of Insurance Company] may deduct one half of [Name of Third Referee]’s reasonable charges and expenses from the settlement amount.

14. Time and mileage for travel for [Name of Third Referee] will compensated based on the time that the he/she leaves his/her home, but in no case shall it exceed the time and mileage it would take to travel from the current offices of the Division.

15. [Name of Third Referee] shall submit to the Division within five (5) days after the date of the final decision a detailed statement of traveling time, the number of meetings held at the site of the loss and/or elsewhere, the actual time of arriving at and leaving said meetings, and such other data as have reference to the decision of the referees. [Name of Third Referee] also shall report to the Division the amount of the award (if any), the amount of his/her bill for services and expenses and whether the award was rendered by a majority of the referees or all three referees.

16. [Name of Insurance Company] and [Name of Insured], if aggrieved by the charges of [Name of Third Referee], may petition the Commissioner for review of such charges. This petition shall set forth with particularity the specific item or charges in dispute. The Division will hold a hearing on the petition in accordance with M.G.L. c. 175, § 101B, after which the Commissioner shall approve or disapprove the disputed charges in whole or in part. The Commissioner’s findings and decisions relative to the petition and disputed charges shall be communicated in writing to the parties and shall be final and conclusive. [Name of Insurance Company]’s payment of the charges of [Name of Third Referee] shall in all instances be in accordance with M.G.L. c. 175, § 101C.

17. If [Name of Insurance Company] or any officer, agent, adjuster or representative thereof having the authority to represent the company in a reference proceeding willfully refuses to comply with a provision of M.G.L. c. 175, §§ 100, 100A or 100D, they shall be punished by a fine of not less than $100 and not more than $500.

18. This Memorandum of Understanding shall be in effect until the resolution of this reference proceeding.

This Memorandum of Understanding may be executed in counterparts and is entered into by:

For the Division of Insurance:

Name

Title

Massachusetts Division of Insurance

1000 Washington St., Suite 810 Boston, MA 02118 For [Name of Insured]:

Name

Title

Address

City, State ZIP For [Name of Insurance Company]

Name

Title

Name of Insurance Company

Address

City, State ZIP For [Name of Third Referee]

Name

Address

City, State ZIP