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____________________, referred to herein as the First Party, and _______________, referred to as the Second Party, agree:

That the parties have a potential claim dispute.

In full and complete settlement of any and all claims under the laws of any applicable jurisdiction, First Party shall pay $____________ to Second Party related to or arising from the claim referred to herein. Said settlement shall also include any attorneys fees or claim/litigation expenses.

This release shall also inure to the benefit of _____________________.

This release shall be contingent upon the approval of the ________________. Upon final approval, which shall be defined as an approval for which no further review is possible, payment shall be made. In the event that the settlement is not approved this agreement shall be void and of no effect.

READ CAREFULLY. THIS IS A FINAL AND BINDING AGREEMENT AND WAIVER OF ALL FUTURE RIGHTS. UPON PAYMENT THE SECOND PARTY WILL HAVE NO FUTURE RIGHTS.

This is the entire agreement between the parties and may only be varied by a writing executed by the parties.

Dated: ___________________

____________________________________

First Party

____________________________________

Second Party

Review List

This review list is provided to inform you about this document in question and assist you in its preparation. Claim settlements, like releases, are a good idea to get memorialized and signed. This form provides that vehicle to effect that action. Use it if in doubt.

1. Make multiple copies. Give one to each signatory. Keep one with the transaction file.

2. Most parties are willing to accept less money immediately after an event than later after brooding over it. This is why insurance companies work hard to get quick settlements. Be so advised yourself to follow their experienced approach to these kinds of matters, if possible in your case.

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To: _______________________________________

GENERAL INFORMATION

1. Claimant

(a) Full name: ________________________________________

(b) Address: __________________________________________

City: _________________________ County: _____________

State: _________________ Zip Code: __________________

(c) Age: _______ (d) Marital status: _______________________

2. If claimant is married, name and address of spouse:

__________________________________________________

__________________________________________________

AMOUNT OF CLAIM

3. Amount claimed for property damage: ___________________

4. Amount claimed for personal injury: _____________________

5. Total amount claimed: ________________________________

ACCIDENT RESULTING IN CLAIM

6. Place of accident (include town or city and state; if outside city limits, indicate distance to nearest city or town):

__________________________________________________

7. Date and time of accident: ____________________________

__________________________________________________

(a) Day of week: ________________________________________

(b) Date: _____________________________________________

(c) Time: _____________________________________________

8. Description of accident

(a) Names and addresses of persons involved: ______________

__________________________________________________

(b) Identification of property involved: ______________________

__________________________________________________

(c) Surrounding circumstances: __________________________

__________________________________________________

(d) Cause of accident: __________________________________

__________________________________________________

(e) Other pertinent facts: ________________________________

__________________________________________________

9. Name and addresses of witnesses to accident: ____________

__________________________________________________

PROPERTY DAMAGE AND PERSONAL INJURY

10. Property damage

(a) Description of property damaged: ______________________

__________________________________________________

(b) Present location: ____________________________________

(c) Name and address of owner, if other than claimant: ________

__________________________________________________

(d) Nature of damage: ___________________________________

(e) Extent of damage: ___________________________________

11. Personal injury

(a) Nature of injury: ____________________________________

_________________________________________________

(b) Extent of injury: ____________________________________

_________________________________________________

INSURANCE COVERAGE

12. Collision insurance

(a) Does claimant carry collision insurance? (If yes, answer (b)- (f) below)

______________________

(b) Name and address of insurer: _________________________

__________________________________________________

(c) Policy No.: _________________________________________

(d) Has claimant filed claim against insurer in this instance?

_________________________________________________

(e) If claim has been filed, is coverage for full amount of loss?

_________________________________________________

If not full coverage, amount deductible: ________________

________________________________________________

(f) If claim has been filed, action taken or proposed to be taken by insurer with respect to claim:

_________________________________________________________

13. Public liability and property damage insurance

(a) Does claimant carry public liability and property damage coverage? (If yes, answer (b) below)

_______

(b) Name of insurer: ____________________________________

I declare under the penalty of perjury that the amount of this claim covers only damages and injuries caused by the accident described above. I agree to accept that amount in full satisfaction and final settlement of this claim.

Dated: __________________________

_______________________________________________

Signature

Review List

This review list is provided to inform you about this document in question and assist you in its preparation. Use this document to transmit your claim to your insurance agency. Be complete; add any necessary and useful exhibits. The more thorough you are the more apt you are to be believed and get prompt payment.

1. Make multiple copies. Give one set to the insurance agency. Keep a backup set (agencies are notorious for losing or misplacing paperwork). Keep one set with the transaction file.

2. Remember that getting paid on a claim is a sales situation. If they are “sold” on your credibility, they will generally pay promptly. If not sold, it can be a long and ugly process. As we have said before, you have one chance to make a good first impression. Do your homework; get a complete and thorough file together; send it to them promptly. All of this will increase the odds of a satisfactory result in your favor.

When a policy is written on a "claims-made" basis, it means that the policy in force at the time a claim against the insured is asserted applies to the claim, regardless of when the occurrence forming the basis of the claim occurred. Correlatively, the policy must be in force at the time that the claim is make for coverage to apply. The insured must also timely report it and follow all conditions precedent outlined in the policy while it is in force. There is a variant of a claims made policy, which may be set forth in an endorsement to the policy, that provides for a "retro" date. This means that the policy will apply to occurrences that took place prior to the inception of the policy (if they otherwise fall within the ambit of coverage).

With an "occurrence" based policy, even though the policy may have expired as of the time the insured received notice of the claim, the policy will afford coverage if the claim otherwise comes within the scope of coverage. This type of policy also has claims reporting provisions to which the insured must adhere, as well as a cooperation clause. The latter means that the insured must cooperate with the insurer (and the attorney it selects to defend that claim) in the defense.

Both forms of coverage have advantages and drawbacks, depending on the circumstances. It is difficult to predict whether, in any particular instance, it will be advantageous to insure using one form or the other. Only in hindsight can a judgment be made.

Advantages of "occurrence" policies

• "Occurrence" policies are sometimes like "money in the bank," in that you can go back to old policies, years after they have lapsed and put a claim against them for incidents that happened while they were in force. Old policies should never be thrown away. They should be kept in a place of safekeeping.
• You don't have to worry about canceling an "occurrence" policy and moving to a different insurer. Coverage remains locked in for incidents occurring while the policy was in force, as long as the insurer is in business. In contrast, once a "claims-made" policy is cancelled, it is possible that purchasing insurance for past events will become difficult, expensive or perhaps not possible.
• Sometimes courts will find occurrences in successive policies if there is continuing harm. This can have the effect of accumulating limits over a period of years. With "claims-made," only one limit applies; that in force when the claim is actually made.

Disadvantages of "occurrence" policies

• Insurance companies that wrote policies in previous years may no longer be in business. With "claims-made" policies, the insurer is much more likely to be around when a claim becomes payable. The length of time between an occurrence and resolution in court can be 20 or more years. An insurer in business 20 years ago may not be in business today. The only way to mitigate this risk with "occurrence" insurers is to change to a different one every few years so that you do not keep "all your eggs in one basket."
• The limits on an "occurrence" policy are likely to be inadequate if a claim is made twenty years after a policy has expired. With "claims-made" it is easier to arrange a limit which is adequate for today's exposures.

For malpractice exposures written on an "occurrence" basis it is important to arrange limits which are somewhat more than is necessary in order to meet tomorrow's exposures. On a "claims-made" basis, one does not need to project twenty years or more into the future when setting limits; 7 years is usually the longest time it takes for a case to go through the court system, so even though you still need to project into the future, the length of time is much less.

Advantages of "claims-made" policies

• Limits can be predicated on today's exposures more accurately than with "occurrence" policies, so there may be less of a likelihood of being underinsured.

Disadvantages of "claims-made" policies

• Coverage is triggered by an actual claim for damages, not a notice of an "occurrence" or "incident." However, the date of the occurrence or incident must be more recent than the retroactive date of the policy. This retroactive date determines the cut-off date for claims: if the incident occurred before the retroactive date, the insurer has no obligation and the insured no coverage. While the claim has to be made during the policy period, the occurrence which gave rise to the claim has to fall after the retroactive date of the policy. A "claims-made" policy wording covers as follows:

This insurance does not apply to "bodily injury" or "property damage" which occurred before the retroactive date, if any, shown in the Declarations.

A "claims-made" policy can have:

• No retroactive date (the broadest coverage).
• A retroactive date that pre-dates the policy inception date (this may range from days to years). Ideally, it should go back at least to the expiration date of your last "occurrence" policy. If it goes back further it can be designed to provide top-up cover in the case of different limits.
• A retroactive date that is the same as the policy inception date - this is the most limited coverage and excludes any claim for damages that occurred prior to the policy inception. It is acceptable only if prior to this policy "occurrence" coverage was in force or full "tail" coverage has been purchased on any previous "claims-made" policy.

Ideally, you want no retroactive date or one that includes the entire period that you have had "claims-made" coverage. Anything less makes you effectively self-insured for any claims for injuries or damage that occurred during prior claims-made policy periods which you have not reported to your insurer at the time of the occurrence (unless such claims are covered by supplemental "tail" coverage).

• The first claim for damages determines which policy applies. For example, if a person first makes a claim for medical payments in 1986, then files for additional damages in 1988, both claims activate the 1986 claims-made policy.
• With "claims-made" basis of coverage, should the policy ever be allowed to lapse or be cancelled, the insured is generally given the option of purchasing coverage, for a stated period following the expiration of the policy (extended reporting period). Any "claims-made" during this extended reporting period month period would then be covered if it otherwise comes within the scope of coverage. With "occurrence" policies you can be less concerned with coverage lapses or insurer changes.
• If coverage terms ever become more restrictive on subsequent renewal of a "claims-made" policy, the new terms apply retroactively to the original retroactive or inception date.

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Date: ____________________________________

Claimant's Name: _____________________________

Address of Claimant: __________________________

___________________________

Name of Carrier: _____________________________

Address of Carrier: __________________________

__________________________

This claim for $ ______ (_____________________________ & ____/100 dollars) is made against the carrier named above by _________________________, Claimant, for overcharge in connection with the following shipment(s):

Description of Shipment: ____________________________

Name and address of Shipper: _________________________

Shipped from ____________________________ to ____________________

Final Destination: ______________________ Routed Via ____________

Bill of lading issued by _______________________ (Company) on the ______________ day of _________________, 19___.

Paid freight bill No. _________________ Truck No. _____________

And initials ___________________________,

Name and Address of recipient __________________.

Nature of Overcharge: __________________________

DETAILED STATEMENT SHOWING HOW AMOUNT CLAIMED IS DETERMINED

Number of packages __________________, articles _______________, weight ___________, rate ___________, charges _____________, amount of overcharge ________________ Dollars.

Authority for rate or classification claimed: __________________________________________

In addition to the information given above, the following documents are submitted in support of this claim:

(___________) 1. Original Bill of lading, if not previously surrendered by carrier.

(___________) 2. Original Paid freight ("expense") bill.

(___________) 3. Original Invoice or Certified Copy.

(___________) 4. Weight Certificate or certified statement when claim is based on misrouting or valuation.

(___________) 5. Other Particulars obtainable in proof of loss or damage claimed: __________.

Remarks: ________________________________________________________

________________________________________________________________

________________________________________________________________.

The above statement of facts is hereby certified as correct.

Dated: ________________________________.

______________________________________

CLAIMANT

Review List

This review list is provided to inform you about this document in question and assist you with its preparation. Claims for price reduction are a standard feature of most commercial businesses. This general format can be adapted to a host of different situations. The more complete the form appears, the more apt you are to get a reduction in price, whether technically merited or not.

1. Make multiple copies. Send one to the signatory by fax and/or mail. Keep one with the transaction file. Note a suitable date, such as 7 days later, to follow up by phone to finalize the result. As with all negotiations, as suggested in our disc of that name, have your end goal in mind when entering into one of these transactions.