RELEASE OF CLAIM AND SUBROGATION RECEIPT
For the sole consideration of ____________ the receipt of which is hereby acknowledged, I/WE _______________ for myself/ourselves, my/our heirs, representative, successors, and assigns, do hereby release and forever discharge _____________ of and from all actions, claims, demand and rights of action whatever that now exist or may hereafter develop and particularly on account of all known and unanticipated injuries, damages and/or losses arising out of and as a consequence of an accident that occurred on or about _______________ at ________________.
I/WE further agree that this Release may be pleaded in bar to any suit or proceeding when I/WE or anyone in my/our behalf, may have taken in connection with the accident herein mentioned; that this payment or service is not an admission of liability by the party or compromise, adjustment and settlement of the claim.
It is further agreed that ____________ is hereby subrogated to all rights of recovery by the undersign on all the aforesaid claim, demand and rights of action from whomsoever may be liable therefore, and is hereby authorized to institute whatever legal proceeding necessary for the endorsement thereof, and to present compromise, adjustment and settlement of the claim.
I/WE manifest that the terms of the Release have been read and/or translated to me in __________, a dialect known to me/us and that I/WE fully understand the contents and import of the same.