Insurance Release Form

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An insurance release form is used by insurance companies to settle claims and protect themselves against liability. When a claimant signs this document, they accept the insurer’s settlement offer and agree to resolve the claim. The settlement often involves a lump-sum payment but may also include non-monetary benefits, such as replacing a totaled vehicle or repairing damaged property.

Insurance Release Form

An insurance release form is used by insurance companies to settle claims and protect themselves against liability. When a claimant signs this document, they accept the insurer’s settlement offer and agree to resolve the claim. The settlement often involves a lump-sum payment but may also include non-monetary benefits, such as replacing a totaled vehicle or repairing damaged property.

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Last updated May 3rd, 2024

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An insurance release form is used by insurance companies to settle claims and protect themselves against liability. When a claimant signs this document, they accept the insurer’s settlement offer and agree to resolve the claim. The settlement often involves a lump-sum payment but may also include non-monetary benefits, such as replacing a totaled vehicle or repairing damaged property.

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INSURANCE RELEASE FORM

1. THE PARTIES. This Insurance Release (“Release”) is made on [DATE] between:

Claimant: [CLAIMANT’S NAME] (“Claimant”) hereby releases:

Insurer: [INSURANCE COMPANY’S NAME] (“Insurer”).

2. RELEASE. The Claimant agrees to hold the Insurer harmless against any and all future claims for the following: [DESCRIBE ACTIVITY BEING RELEASED].

Hereinafter the “Released Activity.”

a.) Compensation. In connection with this Release, there is: (check one)

☐ – Payment Required. A payment of $[AMOUNT] is required to be paid by the Insurer to the Claimait as a condition of this Release.
☐ – Other: [DESCRIBE OTHER COMPENSATION].

3. WAIVER OF CLAIMS. By signing this Release, both parties, including their families, heirs, employees, contractors, agents, and successors, agree to irrevocably release each other from any past, present, or future claims or liabilities without admitting any wrongdoing related to the Released Activity. This waiver settles all disputes related to any potential injuries or damages and is considered legally binding upon its execution and prevents any further claims by any parties or their successors.

4. GOVERNING LAW. This Release shall be governed under the laws of the State of [STATE].

In witness whereof, the Claimant and Insurer authorize this Release on the date indicated below, acknowledging agreement to the terms and conditions of this Release.

Claimant’s Signature: ____________________________ Date: _____________
Print Name: ____________________________

Insurer’s Signature: ____________________________ Date: _____________
Print Name: ____________________________