Fill and Sign the Damage Claim Form

Release by a Guardian for a Minor upon Settlement of a Damage Claim by the Minor in a Law Suit This Release is being executed on the ____ day of ____________, 20___, by ___________________________, of __________________________________ (street address, city, county, state, zip), ("Releasor"), as parent and guardian of ________________________, to ________________________ Company of __________________________________ (street address, city, county, state, zip), ("Releasee"). WITNESSETH Whereas, on _________________ (date), at _______________________________ (location in city, name of county and state), an accident occurred, resulting in bodily injuries to ________________, a minor, born on the ____ day of ____________, _____. (the "Minor"); and Whereas, Releasor is the guardian of the minor as the result of an order entered by the ______________________________________ (specify court) on ___________________ (date), in the action entitled ____________________________, Civil Action No .__________________; and Whereas, claims have been made against Releasee for compensation for such injuries by Releasor as guardian of the minor; and Whereas, a dispute has arisen with respect to the legal liability for such injuries, such liability being expressly denied by Releasee; NOW, THEREFORE, for and in consideration of $__________________ from Releasee, receipt of which is acknowledged by Releasor as the lawful guardian of the above-named minor, Releasor voluntarily and knowingly executes this Release with the intent of effecting the full and final settlement of obligations resulting from said accident and as set forth in this Release. Releasor, with the intention of binding minor, her respective heirs, legal representatives and assigns, releases and discharges Releasee and its successors and assigns from all claims, demands and causes of action that Releasor ever had, now has, or may have arising from such accident and injuries, and by reason of any and all known and unknown, foreseen and unforeseen bodily and personal injuries, damage to property, and the consequences of the same that have been or may after be sustained by the minor and by any other person or persons having a legal interest in consequence of such accident and injuries. Releasor, as the guardian of minor, agrees, in consideration of the above payment, to shall indemnify and hold harmless Releasee, and Releasee's successors and assigns, against loss from any further claims, demands or actions that may subsequently be brought by the minor or by any other person or persons on account of damages of any character resulting in any way from the above-described accident involving minor. IN WITNESS WHEREOF, the parties have signed this Agreement as of the day and date first above mentioned. _____________________________ ____________________________ Releasor Releassee