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: _____________________________________


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