Form 3140F© 2004 Nationwide Publishing Company, Inc.http://www.claimspages.comHOLD HARMLESS AGREEMENTI/WE, the undersigned, in consideration of the payment of DOLLARS ($) to be paid by the ,hereinafter called the Company, do hereby agree to hold the Company harmless from any further claim inrespect to Policy No. or Certificate No. and it is further understood and agreed that in consideration of the payment of the above mentioned sum,we hereby release and relinquish all rights to collect from the Company under the above mentioned policyand/or certificate,... Download File
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Form 2030F © 2003 Nationwide Publishing Company, Inc. http://www.claimspages.com SUBROGATION RECEIPT RECEIVED FROM (Hereinafter referred to as “Company”) THE SUM OF DOLLARS ($) as a loan, without interest, repayable only in the event and to the extent of any net recovery the undersigned may make from any person, persons, corporations,...
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Form 2070F © 2003 Nationwide Publishing Company, Inc. http://www.claimspages.com NON-WAIVER AGREEMENT IT IS HEREBY UNDERSTOOD AND AGREED by and between the parties signing this agreement, that any action taken by (hereinafter referred to as “Company”) in investigating the cause of loss, or investigating and ascertaining the amount...
Form 2120F © 2004 Nationwide Publishing Company, Inc. http://www.claimspages.com PROOF OF HEIRSHIP County of: State of: File Number: We the undersigned, being first duly sworn, do depose and say: First that we are the sole and only heirs of the Estate of deceased, and the relationship which each of us bears to said deceased, is as follows: NAME...
Form 2310F © 2004 Nationwide Publishing Company, Inc. http://www.claimspages.com NON-WAIVER AGREEMENT It is hereby mutually agreed by and between the insured and insurer , as follows; Insurer insures the insured under a Policy Number , with effective dates of through ; and a question exists between the parties hereto as to whether...
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Form 3130F © 2004 Nationwide Publishing Company, Inc. http://www.claimspages.com RESERVATION OF RIGHTS AGREEMENT It is hereby agreed between hereinafter called Insured, and hereinafter called the Company, which has heretofore issued to the Insured its policy No. that any action taken by the Company in investigating that certain accident...
Form 3230F © 2004 Nationwide Publishing Company, Inc. http://www.claimspages.com RECEIPT FOR ADVANCE PAYMENT (THIS IS NOT A RELEASE) This is to acknowledge receipt of dollars ($) paid on behalf of to be credited to the total amount of any final settlement or judgment in my/our favor for alleged damages resulting from an accident on...
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Form 9060F © 2004 Nationwide http://www.claimspages.com Publishing Company, Inc. RECORDED STATEMENT ANALYSIS DATE TAKEN: RECORDED: CLAIM NO. DIRECT TELEPHONE RECORDED AT: INSURED: PERSON INTERVIEWED: (NAME) ADDRESS: TELEPHONE NO: RELATION TO ACCIDENT: INSURED DRIVER INSURED CLAIMANT WITNESS OTHER (Designate) b l ) IDENTIFICATION: AGE...
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Daily log to document activity on a specific claim.
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