Insurance Claims Release

INSURANCE CLAIMS RELEASE

Recitals

WHEREAS, Claimant Name: submitted a claim arising from the incident described below; and

WHEREAS, Released Party: (including its insurers, agents, employees, successors and assigns, collectively the "Released Parties") has agreed to provide consideration to resolve and fully settle such claim;

WHEREAS, the parties intend by this instrument to fully and finally release and discharge the Released Parties from all claims, demands, actions and liabilities arising out of the incident described herein.

Claim and Incident Details

Claim Number:    Incident Date:

Scope of Work

Describe any repair, services, investigation, appraisal or other work performed in connection with this claim. Attach additional schedules if necessary.

Release and Consideration

In consideration of the payment and other promises set forth in this Release, Claimant hereby knowingly, voluntarily and irrevocably releases, acquits and forever discharges the Released Parties from any and all claims, demands, causes of action, liabilities, damages, losses, obligations and expenses (including attorneys' fees) of every kind and nature, whether known or unknown, suspected or unsuspected, disclosed or undisclosed, arising out of or relating to the Incident or the Claim identified above, through the Effective Date of this Release.

This Release extends to any and all claims for personal injury, property damage, consequential damages, emotional distress, economic loss, subrogation claims, and any other theory of recovery, except as expressly reserved below.

Payment Terms

Payment shall be made by the means described in the Payment Schedule. Delivery of funds in accordance with this Agreement constitutes full and complete consideration for the Release. If payment is not timely made in accordance with the Payment Schedule, the Late Payment provision above shall apply and the Released Parties' obligation to perform shall be subject to cure periods set forth in this Agreement.

Term and Termination

This Agreement becomes effective on Start Date: and, except as otherwise provided herein, shall remain in effect until End Date: . Either party may terminate those ongoing obligations that are expressly terminable upon Notice Period: days written notice as provided below, provided that termination shall not reinstate or revive any claim released by this Agreement.

Notwithstanding termination of any ancillary obligation, the Release and Confidentiality provisions shall survive termination to the fullest extent permitted by law.

Confidentiality

Except as required by law, Claimant and Released Parties shall keep the terms, amounts and existence of this Agreement confidential and shall not disclose such information to any third party without the prior written consent of the other party, except to counsel, tax advisors, insurers, and as required in legal proceedings where disclosure is compelled. Breach of this confidentiality obligation shall entitle the non-breaching party to injunctive relief and damages.

Exceptions and Reservations

This Release does not apply to: (a) any rights or claims that cannot be released as a matter of law; (b) obligations under this Agreement not expressly released; and (c) any claims specifically reserved in writing by the parties in an attached schedule. Claimant further acknowledges any existing medical liens or statutory liens and agrees to cooperate with Released Parties to satisfy or address such liens from the Settlement Amount where applicable.

Representations; Tax Treatment

Each party represents and warrants that it has full authority to enter into this Agreement, that it has read and understands its terms, and that it is not relying on any statement or representation not contained in this Agreement. The parties shall be responsible for their own tax reporting and liabilities arising from the Payment; nothing in this Agreement constitutes tax advice.

Indemnification

Claimant agrees to defend, indemnify and hold harmless the Released Parties from any third-party claims arising out of Claimant's intentional misconduct or fraudulent statements related to the Claim. The obligations of indemnification shall survive the execution of this Release.

Governing Law; Venue

This Agreement shall be governed by and construed in accordance with the laws of the State of without regard to its conflict of law rules. The parties submit to the exclusive jurisdiction of the state and federal courts located in the county of for resolution of disputes.

Entire Agreement; Amendment

This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous negotiations, representations, warranties and agreements. This Agreement may be amended only by a written instrument signed by both parties.

Notices

Execution

By signing below, each party acknowledges that they have read this Insurance Claims Release, understand its terms, and intend to be legally bound. Each person signing warrants they have authority to bind the party on whose behalf they sign.

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