m******n
发帖数: 6327 | 1 ☆─────────────────────────────────────☆
toothless (无牙) 于 (Thu Nov 25 09:29:25 2010, 美东) 提到:
前两天看到版上有人问，我就发一个我的保险公司曾经给我的的文本把。这里为什么不
能贴PDF？那就txt将就看吧。
Discharge
I (victim/dischargor's name and address,possibly d.o.b.) ACKNOWLEDGE that I
have agreed to accept from the Dischargees named in the Schedule hereto the
sum of $100.00 in full satisfaction and discharge of all actions suits
claims and demands whatsoever brought by me against the Dischargees and/or
their heirs executors administrators and successors in title arising
directly or indirectly out of an accident which occurred on the date and
place specified in the Schedules hereto and in which I suffered bodily
injury and other loss and damage.
AND I ACKNOWLEDGE that payment of the said sum is with a denial of liability
and to obviate the expense of litigation
AND I FURTHER ACKNOWLEDGE that this Discharge may be placed in bar to any
such action suit claim of demand
AND I FURTHER ACKNOWLEDGE that the said sum is inclusive of those special
damages in the sum of $0.00 already paid by the Dischargees
AND I FURTHER ACKNOWLEDGE that the said sum is subject to the payment of any
charge pursuant to the provisions of the Social Security Act or the Workers
' Compensation Acts or the WorkCover Act or the Health and Other Services (
Compensation) Act, or the Health and Other Services (Compensation) Care
Charges
Act or any other Statute
AND I HEREBY AGREE to indemnify the Dischargees against any claims which may
hereinafter be made against them is respect of any such charge
AND I FURTHER AGREE to indemnify the Dischargees against any claims which
may hereinafter be made against them in respect of the payment to me
hereunder
AND I DIRECT that payment be made to myself whose receipt for such payment
shall be a sufficient discharge.
THE SCHEDULE
1. Dischargor(s) Victim name
2. Dischargee(s) at fault driver or the insurance company
3. Date of Accident date
4. Location of Accident: location
Dated at 30th day of September of 2010
Witness: signature
Discharger: signature
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shadeworks (shadeworks) 于 (Tue Feb 8 01:17:52 2011, 美东) 提到:
这个很有用啊 |
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