A declaration by an insured person that he/she was not being transported for a fee at the time of the accident, and otherwise qualifies for medical expense coverage under the policy.
The insured signs this form which certfies his/her satisfaction with damage repairs performed, directs claim payment to that service provider, and closes the claim.
For a case involving a total loss or theft of a financed motor vehicle or boat, this is an agreement that the lien holder will provide a lien free Certificate of Title to the insurance company upon receipt of a claim payment.