Insurance Settlement Notice

INSURANCE SETTLEMENT NOTICE

Parties and Notice Identification

Insurer Name:    Claim Adjuster:

Date of Birth:    Contact Phone:    Email:

Policy Details

Automobile    Homeowners    Liability    Other:

Coverage Limit: $    Deductible: $    Annual Premium: $

Policy Period: From through

Claim Information

Date of Loss:    Location of Loss:

Police report    Medical records    Photographs    Receipts / Invoices    Other:

Settlement Terms

Total Settlement Amount Offered: $

Payment Method: Check    Wire transfer   Other:

Settlement Effective Date:

Release, Subrogation and Liens

In consideration of the payment described above, the undersigned claimant, on behalf of claimant and claimant's heirs, assigns, representatives and agents, hereby fully and finally releases and forever discharges the Insurer, Insurer's affiliates, representatives, agents, attorneys and any named insured from all claims, demands, actions and causes of action known or unknown, arising from or related to the incident identified in this Notice, subject only to the exclusions and reservations expressly stated in this document.

The claimant acknowledges that Insurer reserves any subrogation rights against third parties and may, at its discretion, pursue subrogation for recovery of amounts paid. The claimant further warrants that there are no outstanding liens or that claimant will cooperate to satisfy valid medical or other liens from settlement proceeds as required by law or agreement.

Confidentiality; Taxes; Exceptions

Unless otherwise required by law, the existence and terms of this settlement are confidential and shall not be disclosed by claimant except to claimant's legal and financial advisors. Claimant is solely responsible for any tax consequences resulting from the settlement and should seek independent tax advice.

Notwithstanding the foregoing release, this Settlement Notice does not waive claims for workers' compensation benefits, benefits payable under separate insurer contracts unless expressly included, or obligations that cannot be waived by law.

Exclusions Acknowledgement

The claimant acknowledges that the settlement does not cover the following unless specifically allocated above (check each acknowledged exclusion):

Punitive or exemplary damages    Future medical expenses not presently incurred    Claims against uninsured or underinsured third parties

Beneficiary Designation (if payment to be made to third party)

If settlement proceeds are to be paid in whole or in part to a beneficiary or payee other than the insured, provide beneficiary information below. If payment is to the insured, leave blank.

Representations and Certification

By signing below, the claimant certifies under penalty of perjury that the information provided in this Insurance Settlement Notice is true and correct to the best of claimant's knowledge, that claimant has read and understands the terms set forth herein, and that claimant has the authority to enter into this settlement and execute the release described above.

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