It is hereby agreed between __________________________________________________________________________
hereinafter called Assured, and ________________________________________________________________________
hereinafter called the Company, which has heretofore issued to the Assured its policy No. ____________________________,
that any action taken by the Company in investigating that certain accident alleged to have occurred on the
_________day of ___________________________, 19 ____________, and all facts pertaining thereto including the cause,
injuries, loss and damages, shall not in any way change, waive, invalidate, or forfeit any of the terms, conditions and requirements
of said policy or any of the rights of either of the parties hereto under sold policy; and in the event any suit has been or shall be
filed against the Assured growing out of said accident, should the Company elect to defend said suit or participate therein, said
defense or participation therein by it shall not be construed to change, waive, invalidate or forfeit any of the terms and conditions
of said policy or any of its rights thereunder. No act of the Company done by way of said investigation or defense shall be
construed as any admission of coverage under said policy.
It is the intention of this agreement to permit a full investigation of said accident and a defense of any suit brought on account of
said accident, should the Company elect to defend, without in any way affecting, impairing or waiving any of the rights of either
party hereto except that the Assured waives the right to insist that such investigation or defense by the Company shall constitute
an admission of liability under said policy.
EXECUTED IN DUPLICATE the _____________day of ___________________________________, 19_________
Witness:
________________________________
Assured
________________________________
Assured
________________________________
Company
By ____________________________