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
