RELEASE AUTOMOBILE ACCIDENT CLAIMS (TYPE 2) Release given on __________ (Date), by ____________________________________, of ___________________________________________________________ (Address), here referred to as Releasor, to ___________________________________________, of _________________________________________________________ (Address), here referred to as Releasee. STIPULATIONS A. Releasor suffered property damage, personal injuries, and other losses as a result of an automobile collision that occurred on ____________ (Date), at _________________ ___________________________ (Specific location), involving Releasor’s automobile, driven by Releasor at the time of the accident, and an automobile driven by Releasee. B. Releasor asserts the collision was caused by the negligence of Releasee. Based on such assertion, Releasor commenced an action for property damages and personal injuries in the __________________________________ (Specify court), Civil Case No. _______________________, entitled _________________________________ v _____________________________. Damages in the amount of __________ Dollars ($__________) as alleged in Releasor’s ________________ (Complaint or petition or declaration) in that action are being sought in such litigation. SECTION ONE RELEASE OF ALL CLAIMS Releasor understands that _____________ (He or she) may have suffered injuries that are unknown to _______________ (Him or her) at the present time and that unknown complications may arise in the future from injuries of which __________ (he or she) is at present unaware. Releasor acknowledges that the possibility of such unknown injuries and complications was discussed in the course of negotiations leading to agreement on the terms of this release, and the sum to be paid by Releasee hereunder was determined with due regard for such possibility. With such knowledge, and in consideration of __________ Dollars ($__________), receipt of which is hereby acknowledged, Releasor elects to and does assume all risks for claims heretofore or hereafter arising, known or unknown, including, without limitation, claims for property damage, direct or indirect medical expense, pain and suffering, disability, and loss of income, based on the automobile accident herein described. Releasor, for __________ (himself or herself) and for __________ (his or her) heirs, legal representatives and assigns, knowingly releases and forever discharges Releasee and __________ (his or her) heirs and legal representatives from all liability with respect to such matters and from all claims and causes of action based in any manner on the accident. SECTION TWO COMPROMISE OF DISPUTED CLAIM Payment of the sum mentioned in Section One hereof is made by Releasee in compromise of a disputed claim between the parties and is intended to extinguish all rights and liabilities concerning such claim. Payment is not to be construed as an admission of liability by Releasee or anyone else. SECTION THREE DISMISSAL OF ACTION Releasor specifically authorizes and directs __________________ (his or her) attorney, ___________________________________ (Name), to execute in duplicate a dismissal with prejudice of the _________________ (Complaint or petition or declaration) in the above-mentioned legal action, and to deliver it to ______________________________ ______________________________ (Name of attorney for Releasee), Attorney at Law, whose office is located at _____________________________________________ _____________________________ (Address, including zip code), contemporaneously with the execution of this release. Thereafter, Releasor shall never assert any claim whatsoever arising from or based on the automobile accident herein described insofar as Releasee is concerned. SECTION FOUR INSURER TO BE COVERED Releasor intends that this release cover ______________________________________ (Name of Releasee’s insurer), an insurance company incorporated under the laws of the State of ______________, and duly licensed to do business in the State of __________, having its principal place of business at ______________________________________ (Address), and the liability insurance carrier of Releasee. SECTION FIVE BASIS FOR RELEASE The consideration stated herein is contractual and not a mere recital. Releasor executes and delivers this release after being fully informed of its terms, contents and effect. Releasor has had the benefit of advice from attorneys and doctors of __________ (His or her) own choosing, and no compromise or representation of any kind has been made to Releasor by Releasee or anyone acting in behalf of Releasee. Releasor understands that this is a full, complete and final release of Releasee, and that the sum of _____________ Dollars ($__________) mentioned above is all the money to be paid to _____________ (Him or her) as a result of the herein-described accident and law suit. In witness whereof, Releasor has executed this release at ________________________ (Designate place of execution) on the day and year first above written. _____________________________________ _______________________ Signature Date ____________________________________ ________________________ Witness Date ____________________________________ ________________________ Witness Date ____________________________________ ________________________ Witness Date