(Full Court Heading)

SPECIAL VERDICT

        We, the jury, answer the questions submitted to us in the special verdict as follows:

        QUESTION NO. 1: Was there negligence on the part of the Defendant (name) which was a proximate cause of the accident?

        ANSWER: Yes ___ No ___

        If you answered the above question "Yes," then please answer Question No. 2. If you answered the above question "No," you will not answer the remaining questions, but will simply sign the verdict.

        QUESTION NO. 2: Was there negligence on the part of the Plaintiff (name) which was a proximate cause of the accident?

        ANSWER:    Yes ___ No ___

        If you answered "No" to Question No. 2, then you will not answer Question No. 3, but will next answer Question No. 4.

        If you answered "Yes" to both prior questions, then answer Question No. 3.

        QUESTION NO. 3: We find that the parties contributed to the cause of the accident in the following percentages:

        (a)    The Plaintiff (name)        _____%

        (b)    The Defendant (name)    _____%

                            TOTAL               100%

        If the percentage of negligence for the Plaintiff is 50% or more, then you will not answer any further questions, but will sign the verdict.

        If the percentage of negligence for the Plaintiff is less than 50%, you will then answer Question No. 4.

        QUESTION NO. 4: What is the total amount of damages sustained by the Plaintiff (name) as a result of the accident?

        ANSWER: $ ______________

                                                            _______________________________

                                                            Foreman