Letter to Claims Adjuster with Release

, 20.




Re: Client:

Date of Accident:

Your claim number:

Your insured:

Dear :

Enclosed please find your Release of All Claims. Accordingly, this will conclude this matter and I will close my file and take no further action.

It has been a pleasure working with you on this file. Thank you for your consideration and cooperation in this regard.

Yours very truly,


Claim Number:



This Indenture Witnesseth that, in consideration of the sum of dollars ($ ) receipt whereof is hereby acknowledged, for myself and for my heirs, personal representatives and assigns,

I do hereby release forever discharge and any other person, partnership, firm or corporation charged or chargeable with responsibility or liability, their heirs, executors, administrators, associates, representatives, successors, and assigns, from any and all claims, demands, damages, costs, expenses, loss of services, actions, and causes of actions arising from any act or occurrence, up to the present time, and particularly an account of all personal injury, disability, property damage, loss of services and loss or damages of any kind sustained or that I hereafter may sustain in

consequence of an accident that occurred on or about day of , , at or near


To procure payment of the said sum, I hereby declare: that I am more than 18 years of age; that no representations about the nature or extent of said injuries, disabilities or damages made by any physician, attorney or agent of any party hereby released, nor any representations regarding the nature or extent of legal liability or financial responsibility of any of the parties released, have induced me to make this settlement; that in determining said sum there has been taken into consideration not only the ascertained injuries, disabilities, and damages, but also the possibility that the injuries sustained may be permanent and progressive and recovery there from uncertain and indefinite. so that consequences not now anticipated may result from the said accident.

I hereby agree that, as a further consideration and inducement for this compromise settlement, that it shall apply to all unknown and unanticipated injuries and damages resulting from said accident, casualty, or event, as well as to those now disclosed.

I understand that the parties hereby released admit no liability of any sort by reason of said accident and that the said payments and settlements in compromise are made to terminate further controversy respecting all claims for damages that we have heretofore asserted or that I or my personal representatives might hereafter assert because of said accident.

I further understand that such liability as I, may or shall have incurred, directly or indirectly, in connection with or for damages arising out of the accident to each person or organization released and discharged of liability herein, and to any other person or organization, is expressly reserved to each of them, such liability not being waived, agreed upon, discharged nor settled by this release.





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Inside Letter to Claims Adjuster with Release