Fill and Sign the Subrogation Form

Subrogation Agreement Authorizing Insurer to Bring Action in Insured's Name 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 the mutual covenants contained in this Agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows: I. Assignment of Claim. Insurer shall pay to Insured on execution of this Agreement $ __________________ under Policy No. __________________ for the damage caused to Insured's property on __________________ (date) , at _____________________________________________ (place of accident) . For the payment of such sum, Insured assigns to Insurer the right to bring an action in Insured's name against any party or person who, or firm, corporation or other entity that may be liable for the same to recover the above-specified loss. Any money that may be recovered by Insured as a result of such action, either by judgment, settlement or otherwise, together with such costs and fees as are allowed by law, will be repaid and paid over to Insurer in accordance with the provisions of Section II of this Agreement. II. Prosecution of Claim. Insured shall prosecute this claim in accordance with the directions of Insurer and represented by counsel provided by Insurer , and Insurer shall bear all the expenses arising out of the disposition of the case. Insured shall receive any moneys paid as a result of such action, which moneys are due to Insurer, as trust funds to be repaid and paid over to Insurer immediately upon receipt of the same. 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)