STATE OF ILLINOIS) )SS COUNTY OF WILL ) IN THE CIRCUIT COURT OF THE TWELFTH JUDICIAL CIRCUIT WILL COUNTY, ILLINOIS _______________________________________ Plaintiff vs CASE NO: ______________________________ _______________________________________ Defendant AWARD OF ARBITRATORS All parties: participated in good faith. did NOT participate in good faith based upon the following findings: __________________________________________________________________________________________________________ __________________________________________________________________________________________________________. We, the undersigned arbitrators, having been duly appointed and sworn (or affirmed), make the following award: FIRST: We find the damages suffered by the Plaintiff as a proximate result of the occurrence in question is $__________________, itemized as follows: The reasonable expense of past medical and medically related expenses $_____________________; The reasonable expense of future medical and medically related expenses $_____________________; The disability/loss of a normal life experienced $_____________________; The disability/loss of a normal life reasonable certain to be experienced in the future $_____________________; The pain and suffering experienced $_____________________; The pain and suffering reasonably certain to be experienced in the future $_____________________; The value of lost wages or earning/profits lost $_____________________; The value of lost wages or earnings/profits reasonable certain to be lost in the future $_____________________; Other: (Fill in specific type of loss) _______________________________________________ $_____________________. SECOND: Assuming 100% represents the total combined fault of all persons or entities whose fault proximately caused harm to plaintiff(s), we find that percent of fault is attributable as follows: (a) Name of Plaintiff ________________________________________________________ _________________% (b) Name of Defendant ______________________________________________________ _________________% (c) Name of Defendant ______________________________________________________ _________________% (d) Name of Non-Party ______________________________________________________ _________________% TOTAL 100% THIRD: After reducing the plaintiff’s total damages by the percent of fault, if any, of plaintiff, we award recoverable damages in the amount of $__________________. FOURTH: We make the following specific findings: ______________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ FIFTH: In addition to the above award, costs in the amount of $_________________________ are awarded to ________________________ _______________________________________itemized as follows: __________________________________________________________ _________________________________________________________________________________________________________________. _______________________________________________________________________________________________________________________ Chair/ Arbitrator (Print Name) (Signature) (ARDC No.) _______________________________________________________________________________________________________________________ Arbitrator (Print Name) (Signature) (ARDC No.) _______________________________________________________________________________________________________________________ Arbitrator (Print Name) (Signature) (ARDC No.) Dissent As to the Award :_________________________________________________________________________________________________ Arbitrator (Print Name) (Signature) (ARDC No.) Dated _________________________________ 20 ______ PAMELA J. MCGUIRE, CLERK OF THE CIRCUIT COURT OF WILL COUNTY White – Court Yellow – Plaintiff Pink – Defendant AR 14 (Revised 08/06) American LegalNet, Inc. www.FormsWorkflow.com