(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 ___

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

        ANSWER: Yes ___ No ___

        If you answered [either of] the above question[s] "Yes," then please answer Question No. 3.

        If you answered [both of] the above question[s] "No," you will not answer the remaining questions, but will simply sign the verdict.

        QUESTION NO. 3. Was there negligence on the part of the Plaintiff (name) which was a proximate cause of the accident?

        ANSWER: Yes ___ No ___

        You are now to compare the negligence of the parties. If you answered "No" to Question No. 3, then insert a zero (0) in answer to Question No. 4(a). If you answered the previous questions "yes," then insert in the answer to Question No. 4 the percentage of negligence you find attributable to each party. Your percentages must total 100%.

        QUESTION NO. 4. We find that the parties contributed to the cause of the accident in the following percentages:

        (a)     The Plaintiff (name)         _____%

        (b)     The Defendant (name)     _____%

        (c)     The Defendant (name)     _____%

                            TOTAL                 100%

        If the percentage of negligence attributed to the Plaintiff is equal to or greater than the percentage of negligence attributed to each Defendant, then you will not answer any further questions, but will sign the verdict.

        If the percentage of negligence attributed to the Plaintiff is less than the percentage of negligence attributed to any Defendant, then you will answer Question No. 5.

        QUESTION NO. 5. What is the total amount of damages sustained by the Plaintiff (name) as a result of this accident?

        ANSWER: $ ______________

DATED this ____ day of _______________________, 19 ___.

                                                   _________________________

                                                   Foreman