of ____________________________________ in the County of _____________________,  State of ________________________ ,
being of lawful age, do for my/our/ its heirs, executors, administrators, successors and assigns, in consideration of the sum

of  ___________________________________________________________________________________ Dollars ($ ___________)

to he paid to _______________________________________________________________________________________________

do by this instrument covenant with _____________________________________________________________________________
to forever refrain from instituting, pressing or in any way aiding any claim, demand, action or causes of action for damages, costs, loss of service, expenses or compensation for, on account of, or in any way growing out of, or hereafter to grow out of in accident which happened to

me/us/it on or about the ________________________________________________________ of _____________________19 _____,

at or near ___________________________________________________________ resulting in indefinite and unknown bodily jury and

property damage.  For the above consideration I hereby agree to hold the said ______________________________________________
harmless from any damage to myself/ourselves/itself resulting or to result from said accident.
 

WITNESS _________________________ hand(s) and seal this_________________ day of _______________, 19 ___,

at_______________________________________ .

In Presence of

                ____________________________________________            ___________________________________________

                ____________________________________________            ___________________________________________

STATE OF____________________________________
                                                                                                            SS.
COUNTY OF__________________________________

 On this _____________________________________ of _____________________________19_____, before me personally appeared

__________________________________________________________________________________________________________

to me known to be the person(s) named herein and who executed the foregoing instrument and  _________________________________
acknowledged to me that --he-- voluntarily executed the same.

My term expires_____________________________ 19______             ___________________________________________________
                                                                                                                                                                            NOTARY PUBLIC

Form Covenant
OHIO INSURANCE DIRECTORY
www.ohioadjusters.com