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Back to Forms for 'Releases and Settlements'.


RELEASE OF INSURER

RELEASE OF INSURER

UNINSURED MOTORIST CASE

 

 

In consideration of __________ Dollars paid by the ____________________________ _________________________ (Name of insurance company), a corporation organized under the laws of the State of __________________ and authorized to transact business

in the State of _______________________, with its principal place of business located at __________________________________________________________ (Address), receipt of which sum is hereby acknowledged, the undersigned, ___________________ ___________________________ (Name), of _________________________________

(Address), releases and forever discharges the ________________________________ (Name of insurance company), and its successors and assigns, from all claims under the Uninsured Motorist Coverage on the company’s policy number _________ and arising out of an accident that occurred on ___________ (Date), at ______________________ (Specify location).

 

In further consideration for the above payment, the undersigned agrees to hold as trustee, for the benefit of the ______________________ (Name of insurance company) beneficiary, all rights, claims and causes of action that the undersigned has or may have against any person or persons, association, organization or corporation because of bodily injury, sickness, illness or death that arose or may arise out of the above-mentioned accident.

 

In conjunction with the conditions and exclusions set forth in the above-mentioned

policy, the trustee agrees to take, through any representative designated by the

beneficiary, such action as may be necessary or appropriate to recover the damages

suffered by the trustee from any person or persons, association, organization or

corporation other than the beneficiary who may be legally liable therefor.  Such action

is to be taken in the name of the trustee, the beneficiary to pay all costs and expenses

in connection therewith, including all reasonable attorney fees.  It is further agreed that

any moneys recovered by the trustee as the result of judgment, settlement or otherwise

will be held in trust and paid to the beneficiary, provided, however, that any sum

recovered in excess of the total amount paid by the beneficiary to the trustee under the

terms of the above-mentioned policy shall be retained by the trustee for the trustee’s

own use and benefit, free of any claim by the beneficiary.

 

 

_____________________________________                      ____________________

Signature                                                                                                           Date

 

 

_____________________________________                      ____________________

Signature                                                                                                           Date

 

 

______________________________________                   ______________________

Witness                                                                                                             Date

 

______________________________________                   ______________________

Witness                                                                                                             Date

 

______________________________________                   ______________________

Witness                                                                                                             Date



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