I/WE, the undersigned, in consideration of the payment of ________________________________________________

DOLLARS ($________________) to be paid by the ___________________________________________________

hereinafter called the Company, do hereby agree to hold the Company harmless from any further

claim in respect to Policy No.  _____________________________  Cert.  No. _______________________________
and it is further understood and agreed that in con s i deration of the payment of the above mentioned sum, we hereby release and relinquish all rights to collect from the Company under the above mentioned policy and/or certificate, and in the event of any further claim, we agree to defend any suit or !)o to any trouble or expense to protect the Company from any further claim under the above referred to policy and/or to assume full responsibility for any necessary further payment or compromise of such claims.
______________________________________________     ____________________________________________LS
            Witness
______________________________________________     ____________________________________________LS
            Witness
______________________________________________     ____________________________________________LS
             Witness
 

ST ATE OF __________________________________________
                                                                                                              SS.
COUNTY OF ________________________________________

On the ______________ day of appeared __________________________________  19 ______, before me personally

appeared ______________________________________________________________________________________

to me known to be the person (s) named herein and who executed the foregoing Release and

___________________________________ acknowledged to me that _______________________________________

voluntarily executed the same.
 

                                                                                                                  _____________________________________
                                                                                                                                                Notary Public

My term expires ______________________________,     19 ___________
 

FORM NO. HOLDHARM
OHIO ADJUSTER S DIRECTORY
www.ohioadjusters.com