Guardian's Covenant Not To Sue Receipt Of Loan


Covenant not to sue executed on __________ (Date) by _______________________ (Name of guardian), of __________________________________________ (Address), to _________________________________________ (Name of insurance company), a corporation authorized to do business under the laws of the State of _______________, with its principal place of business located at __________________________________ (Address).


A. On __________ (Date), at ___________________________________ (Location), _______________________________ and __________________________ (Names), the parents of _________________________ and ___________________________ (Names), the minor children herein, were killed in an accident involving ___________ ____________________________________________________ (Name of tort-feasor).

B. ______________________________________ (Guardian) was appointed guardian ________________________ (pursuant to court order entered on __________ (Date) or pursuant to __________________ (Cite statute) or otherwise as the case may be).

In consideration of the sum of _____________ Dollars received from _____________ _______________________________________ (Insurance company), the undersigned ____________________________ (Name), guardian of the persons and conservator of the estate of ___________________________ and _____________________________ (Names), minors, promises to repay such sum to insurance company, together with interest at the rate of __________ percent per year from ___________ (Date). In further consideration of such loan, the undersigned, individually, and for and on behalf of the minors, agrees not to bring or prosecute or allow to be brought or prosecuted individually or on behalf of the minors, any claims or suits against _______________________________ (Insurance company), for any damages sustained or claimed as a result of such accident and the death of __________________ and ___________________. It is expressly agreed and understood that the undersigned reserves the right to bring suit or claims against ______________________________ ____________________________________________ (Tort-feasor) for such damages.

As additional consideration for the above-mentioned loan, the undersigned agrees to indemnify ______________________________ (Insurance company) against and from all further loss, expense, liability, claims or damages, of whatsoever kind or character, including any and all costs, expenses and reasonable attorney fees, which may be incurred or suffered by reason of any claims, demands, actions or law suits that may be filed or claimed to exist by the undersigned, or that may arise out of or result from any claim for damages for the death of _________________________________________ and _________________________________ filed against _______________________ (Tort-feasor) by the undersigned.

The amount received, __________ Dollars, shall be repayable only out of any recovery obtained on behalf of the minors against _____________________________________ (Name of tort-feasor), of ________________________________________________ (Address), who is deemed by ___________________________________ (Guardian) to be legally liable for the accident in which the parents and natural guardians of the minors were killed. ____________________________________________ (Guardian) agrees to prosecute such claim on behalf of the minors against ____________________ (Tort-feasor) with due diligence, and agrees to appear at all necessary hearings and trials and to cooperate with counsel for ___________________________ (Tortfeasor) in the handling of any such claim of litigation.

As security for repayment of such loan, the __________________________ (Guardian) agrees to hold such loan proceeds in trust and upon trust, as trustee, by deposit or investment in accounts or securities approved by the ___________ (Specify court), and to use such loan proceeds only as necessary for the actual support and maintenance of such minors pursuant to direction and order of the ________________ (Specify court) Such trust shall terminate on the conclusion of the claim or suit to be prosecuted against ________________________ (Tort-feasor) by final judgment, or by settlement, subject to approval of the attorney for _________________________ (Insurance company), or as may otherwise be agreed upon by the undersigned and attorneys.

In witness whereof, I have executed this loan receipt and covenant not to sue at ________________________ (designate place of execution) on __________ (Date).

_____________________________________ Signature

___________________ Date

_____________________________________ Signature

___________________ Date

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