Fill and Sign the Payment Subrogation Form

Receipt for Payment of Loss for Subrogation Whereas, ________________________ (Name of Insured) , of _____________________________________________ (street address, city, county, state, zip code) , referred to herein as the Insured, suffered a loss of $ ______________ compensable under Policy No. ______________ , which loss is described as follows: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ (description of nature and extent of loss) ; and Whereas, Insured acknowledges the receipt of $ ______________ from ________________________ (N ame of Insurance Company) , a corporation organized and existing under the laws of the state of (name of state) , with its principal office located at _____________________________________________ ( street address, city, county, state, zip code) , referred to herein the Insurer, as full settlement of all claims for the above-described loss; Now, therefore, for and in consideration of the above-mentioned payment, Insured assigns to Insurer all claims connected with the above-described loss. Insurer is hereby subrogated in the place of Insured to pursue Insured's claims against any person or entity to the extent of $ ______________ , and Insurer is further authorized to sue or compromise Insured's claim in the name of Insured to the extent of the money paid Insured as documented in this Receipt. Insured covenants that Insured has not discharged the above-described claim against any person or entity and that Insured will furnish Insurer all papers and information in Insured's possession, and will cooperate fully with Insurer and Insurer's attorney(s) to the extent necessary for the proper prosecution of the above-described claim. Insured has executed this receipt at ________________________ (place of execution) on ________________________ (date of execution) . WITNESS my signature as of the ________________________ (date). ______________________ (Signature of Insured) ________________________ (Printed Name) (Acknowledgment)