Insurance Non Waiver Agreement - PDF - PDF by xsm11770


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									                                                                   Claim #:_____________________

                               NON-WAIVER AGREEMENT

It is agreed by and between INDIANA FARMERS MUTUAL INSURANCE COMPANY (hereinafter
referred to as “the company”) and ______________________________________that no action by
way of investigation, compromise or defense of any claims, or actions heretofore or hereafter taken by
the company shall be construed as a waiver of the right of the company to assert any defense which it
has or may have under a policy of insurance designated as # ________________, issued to
________________________________, which is claimed by ___________________________ to
cover an accident or loss which occurred on or about the_____ day of _____________, _______ at or
near _________________________________________.

It is also agreed by INDIANA FARMERS MUTUAL INSURANCE COMPANY that the execution of
this agreement does not waive any rights which _________________________________________ has
or might have under this policy.

WITNESS our hand and seal this ______ day of ______________, ________.

NOTICE: “A person who knowingly and with intent to defraud an insurer files a statement of
         claim containing any false, incomplete, or misleading information commits a felony.”

__________________________ Witness                     __________________________ Signature

__________________________ Witness                     __________________________ Signature

__________________________ Witness                     __________________________ Signature
                                                          Company Representative

STATE OF ________________

COUNTY OF ______________

Subscribed before me a notary public, in and for said County and State, this _______ day of
_____________, __________.

My Commission expires:                              ________________________ Notary Public

_______________________ Date                        ________________________ Printed Name

92-028 (1-01)

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