Form 3
Rules Governing Medical Malpractice Arbitration
Rule Text
Court Administrator Form No. 3 NOTICE TO COURT ADMINISTRATOR OF CONSENSUAL SUBMISSION OF MEDICAL MALPRACTICE CLAIMS TO ARBITRATION ) ) ) ) Malpractice Arbitration V. ) ) Docket No. ) ) ) The following parties hereby notify you of their intent to submit medical malpractice claims to arbitration pursuant to 12 Vermont Statutes Annotated chapter 215: The individual(s) alleging injury and their counsel are: Name Age Born ///Residence (Street) (City or Town) (State) (Zip) (Phone)Business (Street) (City or Town) (State) (Zip) (Phone)Name of Counsel 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)Name of Counsel Business (Street) (City or Town) (State) (Zip) (Phone) The Respondent(s) and their counsel are:Name Age Born ///Residence (Street) (City or Town) (State) (Zip) (Phone)Business (Street) (City or Town) (State) (Zip) (Phone)Name of Counsel 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)Name of Counsel 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 damages 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.) No trial has ever commenced as to the claim asserted. Enclosed is the Arbitration Agreement signed by all parties. The claimant here submits a check or money order made out the Court Administrator in the amount of $100.00. Dated: Signed: (Claimant) The application for a judgment order in accordance with the panel’s decision must be submitted pursuant to 12 Vermont Statutes Annotated § 402. If application is made to the wrong court, it will grant a motion to dismiss without prejudice.