STATE OF SOUTH CAROLINA	)

)	BEFORE THE ARBITRATION PANEL OF COUNTY
In the matter of Arbitration between	)
)

)

)

)

Case number -CP- -
Claimant(s)	)

)	CLAIM FOR PROPERTY DAMAGE

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.

The Defendant(s) resides in County.

The collision occurred in County.

4. The collision occurred on at .

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):

Cl Claimant(s):

DATE:

THIS FORM SHALL BE ARBITRATED BY A PANEL OF THREE (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 CLERK’S OFFICE.

SCCA/201(3/2005)

STATE OF SOUTH CAROLINA

DSmith

2005-03-24

SCJD

South Carolina Judicial Dept.