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Release of Claim With Subrogation Right
Release of Claim With Subrogation Right
I declare that this payment is voluntarily accepted as a full and final compromise,
adjustment and settlement of all claims and that payment of said amount shall never be construed
as an admission of liability.
I hereby manifest that I have thoroughly read and understand the terms of this Release of
Claim with Subrogation Rights.
__________________________________
Insured’s signature over printed name
BEFORE ME, a notary public, this _____ day of ___________ , personally appeared
_______________ with community tax certificate no. _______________ issued at
_______________________________ on _______________ known to me and to me known to
be the same person who executed the foregoing Release of Claim with Subrogation Rights and
he/she acknowledged to me that the same is his/her own free and voluntary act and deed. I further
certify that the contents of the foregoing instrument were fully read and explained to the above
name person to his/her full satisfaction.
WITNESS MY HAND AND SEAL on the day, year and place written above.