Alternate Dispute Resolution Report {100-00294}

Form 294 STATE OF VERMONT COUNTY OF , ss. ) Plaintiff (s) ) ) SELECT COUNTY Superior Court V. ) ) Docket No. ) Defendant(s) ) ALTERNATE DISPUTE RESOLUTION REPORT Date of ADR Session Starting Time Finishing Time 1. Please indicate the names and addresses of all persons participating in the ADR Session. If either party is a corporation or company, please indicate the name and title of the repres entative. Identify with an asterisk the representative of each party who had decision-making authority. Representative & Title, Name Street Address City, State & Zip Code If Applicable Plaintiff Plaintiffs Counsel Defendant Defendants Counsel Insurance Carrier Defendant Defendants Counsel Insurance Carrier Other 2. Please summarize any substitute arrangement made regarding attendance at the ADR Session. 3. Were all appropriate parties in attendance? If no, who failed to appear? 4. Were all parties prepared & did all participate in good faith?If not, who did not comply? 5. Did each party have a representative present with sufficient authorit y to participate in good faith to settle the dispute at thetime of the ADR Session? 6. Did the case settle? (If settlement was reached, please append the agreement of the parties. )7. If the case did not settle: A. Can the scope of the dispute be narrowed by stipulation of the partie s? If so, please describe: B. Did the parties agree to a further ADR session? Yes No N/A Name (printed) Neutral(signature) Date 9/03 SML