Fill and Sign the Subrogation Form

Subrogation Agreement between Insurer and Insured Subrogation Agreement made on the __________________ (date), between ________________________ (Name 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 as the Insurer, and ________________________ (Name of Insured) , of _____________________________________________ (street address, city, county, state, zip code) , referred to herein as the Insured. For and in consideration of $ __________________ , paid by Insurer to Insured under Policy No. __________________ for loss and damage that occurred on __________________ (date of incident) , as follows: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ (Description of Loss and Damage); Insured hereby assigns, transfers and subrogates to Insurer all rights, claims, interest and rights of action, to the extent of the amount above-stated, that Insured may have against any party or person who, or firm or corporation that, may be liable for the loss. Insured authorizes Insurer to sue, compromise or settle in Insured's name, and Insurer is fully substituted for Insured, and subrogated to all of Insured's rights in the description of Insured property to the amount so paid. Insured warrants that no settlement has been made with any third party. It is agreed that any action taken by Insurer shall be without charge or cost to Insured. WITNESS our signatures as of the day and date first above stated. ________________________ (Name of Insurance Company) ______________________ By__________________________ (Signature of Insured) (Signature of Officer) ________________________ ________________________ (Printed Name) (Printed Name and Title)