WHEREAS, on ____________________, ___________________, an insurance company, was presented with a claim arising from:
________________________

under insurance coverage provided to ______________________, under its coverage for:
______________________,

and, WHEREAS, on _________________________, ___________________ paid a claim in an amount of $ ____ (________________ & ____/100 dollars), with a deductible of  $ _____(________ & ____/100 dollars), arising from the perils and covered by the policy stated above, NOW, THEREFORE:
______________________, his heirs and assigns, herewith assign and convey to ________________ and any all rights against any entity who may be liable to ______________________ for the loss stated above.
______________________ shall pursue any and all responsible parties at its own expense, and may at its option, bring such action in its own name or that of ______________________.
______________________ herewith covenants and agrees to fully assist ___________________ in pursuit of its rights of subrogation herein.
___________________ may at its option pursue the deductible loss of ______________________.

In the event that ___________________ does so, it shall notify ______________________, and, further, ______________________ agrees that if any recovery is made that it will share in all costs related thereto pro rata.

______________________ further agrees not to release or exonerate the adverse party or parties or enter into any compromise with them without the prior approval of ___________________.

______________________ shall execute any and all instruments reasonably required by ______________ in connection herewith.

Date: _____________________________________

___________________________________________________
______________________

Subrogation Agreement
Review List
This review list is provided to inform you about this document in question and assist you in its preparation.   This is a technical document that should only be executed by someone expert in the field.

WHEREAS, on ____________________, ___________________, an insurance company, was presented with a claim arising from:
________________________

under insurance coverage provided to ______________________, under its coverage for:
______________________,

and, WHEREAS, on _________________________, ___________________ paid a claim in an amount of $ ____ (________________ & ____/100 dollars), with a deductible of  $ _____(________ & ____/100 dollars), arising from the perils and covered by the policy stated above, NOW, THEREFORE:
______________________, his heirs and assigns, herewith assign and convey to ________________ and any all rights against any entity who may be liable to ______________________ for the loss stated above.
______________________ shall pursue any and all responsible parties at its own expense, and may at its option, bring such action in its own name or that of ______________________.
______________________ herewith covenants and agrees to fully assist ___________________ in pursuit of its rights of subrogation herein.
___________________ may at its option pursue the deductible loss of ______________________.

In the event that ___________________ does so, it shall notify ______________________, and, further, ______________________ agrees that if any recovery is made that it will share in all costs related thereto pro rata.

______________________ further agrees not to release or exonerate the adverse party or parties or enter into any compromise with them without the prior approval of ___________________.

______________________ shall execute any and all instruments reasonably required by ______________ in connection herewith.

Date: _____________________________________

___________________________________________________
______________________

Subrogation Agreement
Review List

This review list is provided to inform you about this document in question and assist you in its preparation.   This is a technical document that should only be executed by someone expert in the field.