Uninsured Motorist Release


This is a sample settlement and release form for an uninsured motorist coverage claim. The release is between the injured driver and their own auto insurance company.


Claim #:  012345372 004

I/we, Jane Driver, Releasor(s) of 8000 Main Street, City of Owings Mills, State of Maryland Being over the age of majority, for and in consideration of a check for the sum of Fifty Thousand and 00/100 Dollars ($50,000.00), lawful money of the United States of America to me/us in hand paid, the receipt of which is hereby acknowledged, do for myself/ourselves, my/our heirs, executors, administrators, successors and assigns, hereby remise, release, and forever discharge GEICO Casualty Company Releasee(s), successors and assigns, and/or his/her/non-binary or their associates, heirs, executors and administrators, and all other persons, firms or corporations of and from any and every claim, demand, right or cause of action, of whatever kind or nature, on account of or in any way growing out of any and all personal injuries and consequences thereof, including, but not limited to, all causes of action preserved by the wrongful death statute applicable, any loss of services and consortium, any injuries which may exist but which at this time are unknown and unanticipated and which may develop at some time in the future, all unforeseen developments arising from known injuries, and any and all property damage resulting or to result from an accident that occurred on or about the 13th day of June, 2019, at or near Baltimore, MD and especially all liability arising out of said accident including, but not limited to, all liability for contribution and/or indemnity. AS A FURTHER CONSIDERATION FOR THE MAKING OF SAID SETTLEMENT AND PAYMENT, IT IS EXPRESSLY WARRANTED AND AGREED:

        (1)    That I/we understand fully that this is a final settlement and disposition of the disputes both as to the legal liability for said accident, casualty, or event and as to the nature and extent of the injury, illness, disease and/or damage which I/we have sustained and I/we understand that liability is denied by GEICO Casualty Company Releasee(s), and it is covenanted and agreed between the Releasor(s) and Releasee(s) herein that this release and settlement is not to be construed as an admission of liability on the part of said Releasee(s); that this release and settlement agreement shall not be used by said Releasor(s) or any one on his behalf as a defense or estoppel in any action which is now pending or may be brought hereafter by said Releasee(s) against said Releasor(s) or his agents and servants, and any claim of whatever kind or nature the Releasee(s) might have or hereafter have arising from said accident is expressly reserved to them.

        (2)  That I/we do hereby for myself/ourselves, my/our heirs, executors, administrators, successors, assigns and next of kin covenant to indemnify and save harmless the Releasee(s) from any and every claim or demand of every kind or character from said accident which may ever be asserted.

        (3)  That no promise, agreement, statement or representation not herein expressed has been made to or relied upon by me/us and this release contains the entire agreement between the parties.

IN WITNESS WHEREOF, I/we have hereunto set my/our hand and seal this __________ day of _________________________, 20________________.




WITNESS:                                 ADDRESS:

WITNESS:                                 ADDRESS:                        


On this _____ day of _______________, 20___________, before me personally appeared ____________________________ known to me or proven to be the person(s) named in and who executed the above release and acknowledged that ________________________________________ executed the same their own free act and deed.


(SEAL):                                                      Notary Public: