AND RESERVATION OF RIGHTS
consideration of $ _________________, receipt of which is hereby acknowledged,
I hereby fully and forever release and discharge
________________________________ (name), of _________________________
(address), and _______________________ (insurance company), a corporation
organized and existing under the laws of the State of _____________ and
authorized to transact business in the State of ______________, with its
principal office for business in the State of ____________________________
located at ________________________________________ (address), their heirs,
administrators, executors, successors and assigns from all claims, demands,
damages, actions, rights of action of whatever kind or nature that I now have
or may hereafter have arising out of, in consequence of, or on account of all
injuries to person, including any latent injuries and all developments and
results therefrom, known and unknown injuries, whether developed or
undeveloped, and anticipated and unanticipated consequences of all such
injuries, and damages to property resulting to me in any way from an accident
that occurred on ____________________ (date), at ______________ (insert
specific location), involving two motor vehicles, in one of which I was a
accepting such sum, I hereby release and discharge that fraction, portion or
percentage of the total cause of action of claim for damages I now have or may
hereafter possess against all parties responsible for my damages which shall by
trial or other disposition be determined to be the sum of the fractions,
portions or percentages of causal negligence for which the parties herein
released are found to be liable to me as a consequence of the above accident.
hereby accept the sum as compromise and settlement of all claims on account of
the dispute between the parties hereto as to whether the above-named parties
are liable to me or not, and also as to the nature, extent and permanency of
the injuries sustained by me.
agree that in making this release, I am relying on my own judgment, belief and
as to all phases of my claims and that I am not relying on representations or
statements made by any of the persons hereby released or anyone representing
them or physicians or surgeons employed by them.
agree that the payment of the above sum is not to be construed as an admission
of any liability whatsoever by or on behalf of the above-named parties, by whom
liability is expressly denied.
further agree that any claim of whatever kind or nature the above-named parties
might have or hereafter have growing out of the above accident is hereby
expressly reserved to them.
release is intended to release only the parties specifically named. The undersigned expressly reserves the
balance of the whole cause of action or any other claim of whatever kind or
nature not released hereby which I may have or hereafter have against any other
person or persons arising out of the above accident.
a further consideration, I agree to indemnify those parties released from any
claims for contributions made by others so adjudged jointly liable with the
parties released, and I agree to satisfy any judgment which may be rendered in
favor of myself, satisfying any fraction, portion or percentage of the judgment
as the causal negligence of the parties released is adjudged to be of all
causal negligence of all adjudged tort-feasors.
the event I fail to immediately satisfy any such judgment to the extent of the
fraction, portion or percentage of the negligence as found against the parties
released, I hereby consent and agree that upon filing a copy of this agreement,
without further notice, an order may be entered by the court in which such
judgment is entered directing the clerk thereof to satisfy the judgment to the
extent of such fraction, portion or percentage of the negligence as found
against the parties released and discharged under this release.
do hereby specifically reserve any rights I might have against
___________________ (name), of
____________________________________________________ (address), and
_________________________________________________ (insurance company), of
__________________________________________________________ (address), and any
of the above arising out of the above mentioned accident.
witness whereof, I have executed this release at _____________________________
(designate place of execution) on _____________________________________ (date).