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.
_________________________ _____________________
Signature
Date
_________________________ _____________________
Signature Date
