RELEASE PROVISION

SUBROGATION TO CERTAIN CLAIMS

Releasor agrees that releasee shall be subrogated to the extent of $__________, to all rights, claims, actions or causes of action that releasor may have against any other person, firm or corporation by reason of _____________________________________

_______________________ (injuries and damages sustained by releasor in the above-described accident).

Releasor authorizes releasee, ________________________ (Name of Releasee) __________________________ (Releasee's heirs, legal representatives and assigns) to collect, compromise or sue in releasor's name for the amount of damages so sustained by releasor. In the event that releasor should file suit against any other person, firm or corporation for injuries sustained in the above described accident, releasor assigns to releasee and his or her heirs, legal representatives and assigns, such interest in the claim to sufficiently reimburse releasee for the above stated sum with interest from this date.

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Signature Date

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Signature Date