STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS SUPERIOR COURT SELECTION OF ARBITRATOR Plaintiff Defendant Civil Action File Number ATTORNEY FOR THE PLAINTIFF OR THE ATTORNEY FOR THE DEFENDANT OR PLAINTIFF (NAME AND ADDRESS) THE DEFENDANT (NAME AND ADDRESS) The below-named attorney has been mutually selected as the arbitrator in the above-entitled case. _____________________________________________ Arbitrator Rhode Island Bar Number Date /s/ __________________________________________________________ Attorney for the Plaintiff or the Plaintiff Telephone Number: /s/ __________________________________________________________ Attorney for the Defendant or the Defendant Rhode Island Bar Number Date Telephone Number: THIS FORM MUST BE FILED (ELECTRONICALLY IF APPLICABLE) WITH THE ARBITRATION OFFICE, LICHT JUDICIAL COMPLEX, 250 BENEFIT STREET, ROOM 531, PROVIDENCE, RI 02903 ONCE THE REQUIRED INITIAL ARBITRATION FEES HAVE BEEN PAID AND WITHIN FIFTEEN (15) DAYS OF A NOTICE OF DESIGNATION TO ARBITRATION AND APPOINTMENT/SELECTION OF ARBITRATOR, OR AN ARBITRATOR WILL BE APPOINTED BY THE COURT. Processed by Arbitration Office Superior-32 (revised September 2015) American LegalNet, Inc. www.FormsWorkFlow.com