RELEASE OF ALL CLAIMS AS A RESULT OF
THE DEATH OF _____________________________
FOR AND IN CONSIDERATION OF THE SUM OF ____________________ ($_________________ ) in the form of checks or drafts payable as follows:
AND _______________________________, as personal representative of the Estate of ___________________________ as payees, which sum shall be deemed to have been paid upon the delivery of such drafts or checks to the undersigned, the undersigned on behalf of the undersigned, and on behalf of all and each of the heirs, executors, administrators, successors and assigns of the undersigned, (hereinafter referred to as “Releasors”) hereby releases and forever discharges _________________________________ of and from any and all claims, demands, damages, actions and causes of action of every kind, known and unknown, including but not limited to any and all claims for wrongful death, personal injuries, or property damage, including but not limited to loss or destruction of, or damage to, baggage, and any claims for refunds or monies paid by the passenger involved for travel on a certain ______________________, arising out of or in any way connected with a _______________________ accident which occurred on ___________________, 20___ at _______________________________.
The undersigned hereby certifies that the relationship listed beneath the undersigned’s signature is true, and further that in the event there is no executor or administrator a party signatory to this release, that there are no other heirs at law other than those whose signatures appear below.
IN FURTHER CONSIDERATION of the above mentioned sum, the undersigned agrees as follows:
1. There is a risk that subsequent to the execution of this release the undersigned will incur or suffer personal bodily discomfort, monetary or other loss, death, damage or any of these which are in some way caused by or related to the occurrence referred to above, but which are unknown and unanticipated at the time this release is signed; and further there is a risk that the damages presently known may be or may become more extensive than the undersigned now expects to anticipates.
2. The undersigned shall assume the above mentioned risks, and this release shall apply to all unknown or unanticipated results of the occurrence described above as well as those known and anticipated.
3. The above mentioned sum is the entire and only consideration for this release and the undersigned shall be responsible for the payment of the attorney’s fees and legal expenses of the undersigned.
4. It is intended by Releasors and Releasees, and each of them, that this release shall be complete and shall not be subject to any claim of mistake of fact or law by the undersigned, and that it expresses a full and complete settlement of liability claimed and denied, as against Releasees and, regardless of the adequacy of inadequacy of the amount paid, this release is intended to avoid litigation and to be final and complete.
5. This release is the result of a compromise of a disputed claim and shall never at any time for any purpose be considered as an admission of liability or responsibility the parties hereby released, who continue to deny such liability and to disclaim such responsibility.
6. A division, if any, of the above mentioned sum between the undersigned and anyone else shall in no way affect the validity of this release.
7. This settlement is in complete satisfaction of any and all claims and counterclaims arising from the incident in question and from this litigation.
8. It is the express intent and understanding of the Releasors and Releasees that any and all rights of indemnity and/or contribution or other derivative claims that any Releasee may have against any other Releasee or Releasees or other persons, firms or entities shall be preserved by the execution of this release. It is agreed and stipulated by the undersigned that the amount paid in consideration for this release is a fair and reasonable settlement.
9. It is also the express intent and understanding of the Releasors and Releasees that in consideration of said payment and all of the foregoing, Releasors hereby assign, transfer, set over and subrogate to Releasees, their successors and assigns, all of Releasors’ rights, title and interests in and to any and all such claims of Releasors arising in any manner, or associated in any way with the accident involving a certain _______________________ at ______________________________________________.
as personal representative of the Estate
STATE OF ________________________
COUNTY OF _______________________
On this the ___ day of _____________, 20___ , before me, a duly commissioned and sworn Notary Public in and for the above State and County did appear ____________________ before me signed the within instrument. I know that each said signed of the within instrument is the person whose name is subscribed.
IN WITNESS WHEREOF, I have hereunto signed my name and affixed my official seal in the above named personal representative as of this date.
My Commission Expires:
I am an attorney licensed to practice law in this State, and I hereby represent and declare that I have fully explained the foregoing Release to _________________________________, who in turn acknowledged to me an understanding of said Release and the legal effect thereof; and each signature on the Release was personally made by the person whose name it is.
State Specific Release Forms
—-For State Specific Release Forms you can download in Word Format go to