STATE OF SOUTH CAROLINA ) BEFORE THE ARBITRATION PANEL OF ) ____________________ COUNTY In the matter of Arbitration between ) ) ) Case number ____-CP-____-______ ) ) Claimant(s) CLAIM FOR PROPERTY DAM) AGE ) vs. ) ) ) Defendant(s) ) The Claimant(s), complaining of the Defendant(s) hereby files a claim for property damages arising out of a motor vehicle collision and requests that the matter be submitted to arbitration, and allege: 1. The Claimant(s) resides in _________________ County. 2. The Defendant(s) resides in _________________ County. 3. The collision occurred in _________________ County. 4. The collision occurred on ______________ at _________________ ______________________ __________________________________________________________________ ______________. 5. As a result of said collision, due to the negligent and reckless acts of the Defendant(s), the Claimant(s) have suffered property damage in the amount of _______________________________________________________________, actual and punitive. WHEREFORE, Claimant(s) requests that this claim be arbitrated and that property damages be awarded in the amount of ____________________________________________________________ _________________________________________, actual and punitive. Attorney for Claimant(s): Claimant(s): DATE: ___________________ THIS FORM SHALL BE ARBITRATED BY A PANEL OF TH REE (3) ARBITRATORS TO BE APPOINTED BY THE CLERK OF COURT UNLESS WITHIN TEN(10) DAYS FROM THE FILING OF A RESPONSE BY THE DEFENDANT(S), THE CLAIMANT(S) AND DEFENDANT(S) SHALL AGREE, IN WRITING, TO HAVE SUCH CLAIM HEARD BY A SINGLE ARBITRATOR. A FORM OF AGREEMENT IS AVAILABLE IN THE CLERKS OFFICE. SCCA/201(3/2005) American LegalNet, Inc. www.USCourtForms.com