WHEREAS, on ____________________, ___________________, an insurance company, was presented with a claim arising from:
under insurance coverage provided to ______________________, under its coverage for:
and, WHEREAS, on _________________________, ___________________ paid a claim in an amount of $ ____ (________________ & ____/100 dollars), with a deductible of $ _____(________ & ____/100 dollars), arising from the perils and covered by the policy stated above, NOW, THEREFORE:
______________________, his heirs and assigns, herewith assign and convey to ________________ and any all rights against any entity who may be liable to ______________________ for the loss stated above.
______________________ 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 ______________________.
______________________ herewith covenants and agrees to fully assist ___________________ in pursuit of its rights of subrogation herein.
___________________ may at its option pursue the deductible loss of ______________________.
In the event that ___________________ does so, it shall notify ______________________, and, further, ______________________ agrees that if any recovery is made that it will share in all costs related thereto pro rata.
______________________ further agrees not to release or exonerate the adverse party or parties or enter into any compromise with them without the prior approval of ___________________.
______________________ shall execute any and all instruments reasonably required by ______________ in connection herewith.
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