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Agreement To Execute

(Accidental Injuries)

Agreement made on __________ (date), between __________ (name), of _____________ (address), and ____________ (name), of _____________ (address).

In consideration of the payment to me by _________ (name of covenantee) of the sum of ____________ Dollars ($__________ ), receipt whereof is hereby acknowledged, I hereby undertake and agree that on the payment to me at any time on or before ________ (date) of the further sum of $ ______, I will execute and deliver to _________ (name of covenantee) a covenant not to sue __________ (him or her) on any claim or cause of action that I may have against ___________ (him or her), arising out of a certain __________ (motor vehicle) accident that occurred at _____________ (insert description), on or about __________ (date).

The covenant not to sue shall be in the form attached and made a part of this document.

The payment to me shall be made either to myself at ______________ (address), or to my attorney, _____________ (name), of ____________ (address), and may be made in the form of cash, ___________ (cashiers) check or draft, the payment of which is guaranteed by _________ (name of guarantor), of _____________ (address).

If I refuse to execute a covenant not to sue, then on payment of the sum of $_________ to either myself or the above-mentioned ____________(name of attorney), this agreement will be deemed to operate as such covenant not to sue and the terms of the covenant not to sue attached to this document shall be binding on me as if then executed.

In witness whereof, the parties have executed this agreement at __________ (designate place of execution) the day and year first above written.

Date: ______________

_______________________

Signature

_______________________

Signature

(Attach covenant not to sue.)

(Attach statement of attorney, if required.)

This Section for Notary:

ACKNOWLEDGMENT

State of _________

County of ________ [COUNTY]

On [DATE] before me, [NAME OF NOTARY], notary, personally appeared [NAME OF PERSON(S) INVOLVED], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

Witness my hand and official seal.

Signature ________
Notary

My commission expires: _____