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.

Date: _____________________________________

___________________________________________________