How To Use
This review list is provided to inform you about this document in question and assist you in its preparation. This is a technical document that should only be executed by someone expert in the field.
WHEREAS, on _________________, _______________________________, an insurance company, was presented with a claim arising from: ________________________ under insurance coverage provided to _________________________, under its coverage for: __________________________________,
and, WHEREAS, on _________________________, _______________________________ paid a claim in an amount of $_________ (__________________________________________ & _____/100 dollars), with a deductible of $__________ (______________________________________________ & ____/100 dollars), arising from the perils and covered by the policy stated above,
_________________________, his heirs and assigns, herewith assign and convey to _________________________ and any all rights against any entity who may be liable to ______________________ for the loss stated above.
_________________________ shall pursue any and all responsible parties at its own expense, and may at its option, bring such action in its own name or that of _______________________________________.
_________________________ herewith covenants and agrees to fully assist _________________________ in pursuit of its rights of subrogation herein.
_________________________ may at its option pursue the deductible loss of ________________________________.
In the event that ________________________ does so, it shall notify __________________________, and, further, __________________________ agrees that if any recovery is made that it will share in all costs related thereto pro rata.
_________________________ further agrees not to release or exonerate the adverse party or parties or enter into any compromise with them without the prior approval of _______________________________.
_________________________ shall execute any and all instruments reasonably required by __________________________ in connection herewith.