Form 2

Court Administrator Form No. 2 AGREEMENT TO ARBITRATE MEDICAL MALPRACTICE CLAIMS The individual(s) here alleging injury resulting from medical malpractice are: Name Age Born //Residence (Street) (City or Town)(State)(Zip) (Phone)Business (Street) (City or Town)(State)(Zip) (Phone) Name Age Born ///Residence (Street) (City or Town) (State) (Zip) (Phone)Business (Street) (City or Town) (State) (Zip) (Phone) The Respondent(s) are:Name Occupation Residence (Street) (City or Town) (State) (Zip) (Phone)Business (Street) (City or Town) (State) (Zip) (Phone) Name Occupation Residence (Street) (City or Town) (State) (Zip) (Phone)Business (Street) (City or Town) (State) (Zip) (Phone) The claim asserted is the following: (State the nature of the claim including the time of occurrence, the place, the circumstances, the alleged negligent or omission, the injury or damage sustained, the relief demanded and the date upon which the claimant became aware of the nature existence of the claim. Use additional paper if necessary.) We, the above parties, hereby agree: (1) To arbitrate the above claim pursuant to 12 Vermont Statutes Annotated chapter 215; (2) That no claims or cross-claims in this arbitration will be filed against individuals or entities who have not joined in agreement and signed below; (3) That once a claim has been filed with the Court Administrator, a party to the proceeding may withdraw and a claim may be withdrawn from arbitration only upon written consent of other parties; (4) That before any party signing below may sue another party signing below on any of the above claims, either one or more of parties to the suit must have withdrawn from arbitration, or the claim must have been withdrawn from arbitration. Signed: Dated: