(Full Court Heading)

SPECIAL VERDICT

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

        QUESTION NO. 1. Was the defendant (name) negligent, which negligence was a proximate cause of the accident?

        ANSWER: Yes _____ No _____

        QUESTION NO. 2. Was the defendant (name) negligent, which negligence was a proximate cause of the accident?

        ANSWER: Yes _____ No _____

        QUESTION NO. 3. Was the plaintiff (name) negligent, which negligence was a proximate cause of the accident?

        ANSWER: Yes _____ No _____

        If you have answered "Yes" to either [any] of the prior questions, then answer the next question.

        QUESTION NO. 4. Considering all the negligence [, as among the parties,] that cause the accident at one hundred percent (100%), what percentage is attributable to:

        (a)    The Plaintiff (name)         _____%

        (b)    The Defendant (name)     _____%

        (c)    The Defendant (name)    _____%

                        TOTAL                   100   %

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

        ANSWER: $ __________

        QUESTION NO. 6. What is the total amount of damages sustained by the defendant (name) as a result of the accident?

        ANSWER: $ __________

        QUESTION NO. 7. What is the total amount of damages sustained by the defendant (name) as a result of the accident?

        ANSWER: $ __________

        DATED this ___ day of ____________________, 19__.

                                                        ______________________________

                                                        Foreman

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