Uninsured Motorist Sworn Statement In Proof of Loss



STATE OF __________.

COUNTY OF _________.

I hereby claim under the uninsured motorist coverage provided to ___________, 20 __, under policy number _______________, policy period commencing ___________, 20 _, concluding ___________, 20 _, the total sum of $------- (dollars) as the full amount of uninsured motorist losses, including the following expenses incurred in relation to said accident:

See exhibit 1 attached hereto

Place of accident: Date of accident: [Date]

The persons or company who I contend is legally liable to me for my injuries is _________________________.

Dated:

_______________________

Sworn to and subscribed before me by on __________________.

_________________________

Notary Public

My Commission expires:

[Do not sign the Release agreement until agreement with the INSURANCE COMPANY as to settlement]

RELEASE AND TRUST AGREEMENT

In consideration of the sum of $------ (& no/100 dollars), received from INSURANCE COMPANY, I hereby acknowledge full satisfaction and release all claims and demands against the INSURANCE COMPANY, by reason of the accident, and agree to take such as action as may be necessary to recover damages from the person or entity who is liable, or others, through legal counsel chosen by INSURANCE COMPANY, at the expense of the INSURANCE COMPANY.

I agree to fully reimburse the INSURANCE COMPANY from any recovery made, for its payments herein, after the deduction of the expenses of suit, including attorney's fees, the full amount of the payment, plus interest at the rate of percent from date of payment, to the extent of recovery.

I further agree that the INSURANCE COMPANY shall have the sole right to authorize settlement of the claim, and that I may not agree to a settlement of the claim without the prior authority of the INSURANCE COMPANY.

_____________________________