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(Note: This agreement permits an insurance company to settle your claim, in exchange for the right to pursue reimbursement from the persons who caused the damage.)
WHEREAS, on [Date], ABC Insurance, an insurance company, was presented with a claim arising from:
under insurance coverage provided to Policyholder, under its coverage for:
WHEREAS, on [Date], ABC Insurance paid a claim in an amount of [$------], with a deductible of [$------], arising from the perils and covered by the policy stated above. Now, therefore:
Policyholder, his heirs and assigns, herewith assign and convey to ABC Insurance and any all rights against any entity who may be liable to Policyholder for the loss stated above.
Policyholder 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 Policyholder.
Policyholder herewith covenants and agrees to fully assist ABC Insurance in pursuit of its rights of subrogation herein.
ABC Insurance may at its option pursue the deductible loss of Policyholder. In the event that ABC Insurance does so, it shall notify Policyholder, and, further, Policyholder agrees that if any recovery is made that it will share in all costs related thereto pro rata.
Policyholder further agrees not to release or exonerate the adverse party or parties or enter into any compromise with them without the prior approval of ABC Insurance. Policyholder shall execute any and all instruments reasonably required by ABC Insurance in connection herewith.
This Section for Notary:
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.
My commission expires: _____