STATE OF SOUTH CAROLINA ) BEFORE THE ARBITRATION PANEL OF ) ____________________ COUNTY In the matter of Arbitration between ) ) ) Case number ____-CP-____-______ ) ) Claimant(s) ) AGREEMENT ) vs. ) ) ) Defendant(s) ) Pursuant to the South Carolina Automobile Reparation Reform Act of 1974, 38-77-710, et seq., as amended, the undersigned hereby request and agree that the arbitration of a property damage claim between ___________________, and ___________________, Defendant(s) arising out of a motor vehicle collision or accident shall be had before a single arbitrator to be designated and appointed by the Clerk of Court for __________________ County, in li eu of a panel of three arbitrators, all as provided under S.C. Code Ann. 38-77-720. IN WITNESS WHEREOF, we have hereunto set our hands and seals this _____day of ___________, ______. ___________________________________ Claimant __________________________________ Defendant ___________________________________ Defendant SCCA/205(3/2005) American LegalNet, Inc. www.USCourtForms.com