Liability Claims Form

Liability Claims Form

This Liability Claims Form is executed by and between Claimant Name: (hereinafter "Claimant") and Respondent Name: (hereinafter "Respondent"), each a "Party" and together the "Parties."

RECITALS

WHEREAS, Claimant asserts that on or about the date set forth below an event occurred that gave rise to alleged bodily injury, property damage, economic loss or other harm for which Claimant seeks recovery;

WHEREAS, Respondent may have potential liability arising from the circumstances described in this Form and the Parties wish to record the Claimant's allegations and supporting information for investigation and resolution; and

WHEREAS, the Parties intend that the submission of this Form will preserve facts for investigation and is submitted without admission of liability by any Party.

NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the Parties agree as follows:

1. DEFINITIONS

For purposes of this Form: "Claim" means the asserted demand for relief arising out of the Incident described below; "Incident" means the event described in Section 2; "Confidential Information" means non-public information exchanged in connection with the investigation of this Claim.

2. CLAIM DETAILS

Claim Reference Number:

Date of Incident: / /

Location of Incident:

Amount Claimed (if applicable): $

Police Report Number (if any):

Insurer (if applicable): Policy No.:

3. SUPPORTING DOCUMENTS

Please indicate which documents accompany this submission (check all that apply):

Police report Medical records Photographs

Repair/repair estimates Witness statements Other:

4. INVESTIGATION AND COOPERATION

Claimant agrees to cooperate reasonably and in good faith with Respondent and any appointed investigators. Cooperation includes, but is not limited to, providing medical releases, copies of relevant records, sworn statements, and access to documents or property reasonably necessary to investigate the Claim.

Claimant hereby authorizes the release of records reasonably necessary for the investigation of this Claim to Respondent and its representatives, subject to applicable privacy laws, by initialing here:

5. RESERVATION OF RIGHTS

Submission of this Form and any supporting materials is for purposes of investigation and does not constitute an admission of liability or waive any defenses available to Respondent. Respondent reserves all rights to contest liability, causation, or damages.

6. PRIVACY AND CONFIDENTIALITY

Documents and information exchanged for investigation are subject to confidentiality to the extent permitted by law. Confidential Information shall be used solely for investigation and resolution of the Claim and shall not be disclosed except as required by law or court order.

7. NOTICES

Notices required or permitted under this Form shall be delivered to the addresses provided below and shall be effective upon receipt.

8. GOVERNING LAW; OTHER PROVISIONS

This Form shall be governed by and construed in accordance with the laws of the state of , without regard to conflict of law principles.

Entire Agreement: This Form constitutes the entire agreement of the Parties with respect to the subject matter herein and supersedes all prior written or oral communications concerning the Claim.

Amendments and Waiver: No amendment or waiver shall be effective unless in writing and signed by both Parties. No waiver of any breach shall be a waiver of any subsequent breach.

Severability: If any provision of this Form is found to be unenforceable, the remaining provisions shall remain in full force and effect.

9. CERTIFICATION

Claimant certifies under penalty of perjury that the information contained in this Form is true and correct to the best of Claimant's knowledge and belief, that Claimant is the person entitled to submit this Claim, and that all supporting documents submitted are genuine to the best of Claimant's knowledge.

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