HomeMy WebLinkAboutBest Limo/Brian Thompson 4) -00 kb). Oat CC-
RELEASE OF ALL CLAIMS Claim#: 6493 S -JN
PROPERTY DAMAGE ONLY
APPROVED, a(3
FORM BY: Z5
KNOW ALL MEN BY THESE PRESENTS:
That the Undersigned, being of lawful age, for the sole consideration of Seven Hundred Ninety Nine and 98/100 Dollars
($799.98) to the undersigned in hand paid, receipt whereof is hereby acknowledged, do/does hereby and for my/our/its heirs,
executors, administrators, successors and assigns release, acquit and forever discharge Best Limo Service. Inc. and Brian
Thompson (driver) and Stratford Insurance Company and his, her, their, or its agents, servants, successors, heirs, executors,
administrators _ ' " " , "` .. 1 of and from any and all claims, actions,
causes of action, demands, rights, damages, costs, loss of service, expenses and compensation whatsoever, which the
undersigned now has/have or which may hereafter accrue on account of or kcal." growing out of any and all known and
unknown, foreseen and unforeseen bodily and personal injuries and property damage and the consequences thereof resulting or to
result from the accident, casualty or event which occurredAon or about the 18th day of January, 2000, at or near Hazeldell
Parkway. Carmel. IN. atxayout S 3ga. .
It is understood and agreed that this settlement is the compromise of a disputed claim, and that the payment
made is not to be construed as an admission of liability on the part of the party or parties hereby released, and that said releases
deny liability therefor and intend merely to avoid litigation and buy their peace.
The undersigned hereby declare(s) and represent(s)that the injuries sustained are or may be permanent and progressive
and that recovery therefrom is uncertain and indefinite and in making this Release it is understood and agreed, that the undersigned
rely(ies)wholly upon the undersigned's judgment, belief and knowledge of the nature, extent, effect and duration of said injuries and
liability therefor and is made without reliance upon any statement or representation of the party or parties hereby released or their
representatives or by any physician or surgeon by them employed.
The undersigned further declare(s) and represent(s)that there may be unknown or unanticipated injuries resulting from the
above stated accident, casualty or event and in making this Release it is understood and agreed that this Release is intended to
include such injuries.
The undersigned further declare(s) and represent(s) that no promise, inducement or agreement not herein expressed has
been made to the undersigned, and that this Release contains the entire agreement between the parties hereto, and that the terms
of this Release are contractual and not a mere recital.
This Release expressly reserves all rights of the person, or persons, on whose behalf the payment is made and the rights
of all persons in privity or connected with them, and reserves to them their right to pursue their legal remedies, if any, including but
not limited to claims for contribution, property damage and personal injury against the undersigned or those in privity or connected
with the undersigned.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURANCE COMPANY OR
OTHER PERSONS, FILES A STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS
FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT, MATERIAL THERETO, COMMITS A
FRAUDULENT INSURANCE ACT,WHICH IS A CRIME,SUBJECT TO A CRIMINAL PROSECUTION AND CIVIL PENALTIES.
THE UNDERSIGNED HAS READ THE FOREGOING RELEASE AND FULLY UNDERSTANDS IT.
Signed, sealed and delivered this (Oil) day of ( I( OTC)/& )OY ,
CAUTION: READ,,BEFO SIGNING BELOW ll
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fitness i" y of r el,Inc.
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STATE OF IkiblAMA.
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COUNTY OF kw!L"ioki
On the LA day of cAatOrnht r' ,WOO, before me personally appeared ✓ifWS a'rhaRq1
Macy Ann Ste'ke Billy L. &lat Ices LS
to me kno n to be the person(s) named herein and who executed the foregoing Release and wh 0 acknowledged
to me that to r? voolluntar'y,executed the sa
My term expires -/ t .r t e/✓ -7 , s fC. 7..�[ C. ?et
Notary Pub'
RLPL
-Stratfordq NO. 0019688
INSURANCE COMPANY Bc ea,rz
400 Parson'a Pond Drive
Franklin Lakes,New Jersey, 07417-2600 , TJI& 'IJ .;,,CLAIMIIO 4- AMQUT•$T<
4/05/00 006493 S $79998
PAY *******799 DOLLARS AND 98 CENTS
Commerce Bank North
1100 Lake Street
TO THE CITY OF CARMEL,INC. Ramsey,N.J. 07446
ORDER
OF
SIGNATURE HAS A COLORED BACKGROUND•BORDER CONTAINS MICROPRINTNG
000 L 9 688i1• 1:0 2 L 200 9 5 71: 5 0 L 358 5ii•
DETAC AND
THE ATTACHED CHECK IS IN PAYMENT OF ITEMS DESCRIBED BELOW. C
IF NOT CORRECT PLEASE NOTIFY US PROMPTLY.NO RECEIPT DESIRED.
Stratford Insurance Company
ATTACHED IS OUR CHECK #0019688 IN THE AMOUNT OF $799.98
IN FULL SETTLEMENT OF THE ABOVE CAPTIONED CLAIM. ENCLOSED IS A
RELEASE TO BE SIGNED, NOTARIZED AND EXCHANGED FOR THE CHECK.
CITY OF CARMEL, INC.
ATTN. DAVID W. KLINGENSMITH
CARMEL STREET DEPARTMENT
211 2ND STREET S.W.
CARMEL, IN 46032
CITY OF CARMEL, INC. VS. BEST LIMO SERVICE, INC
NO. 0019688
DESCRIPTION CLAIMANT DATE OF CHECK
SETTLEMENT PAYMENT CITY OF CARMEL, INC. 4/05/00
POLICY NO. INSURED DATE OF LOSS
BAP0706477 BEST LIMO SERVICE, INC 1/18/00
AGENT BROKER CLAIM NO. CLMNT NO. EXAMINER
CODE I
00399 006493 S 02 0038
VENDOR NO. INVOICE NO. DATE OF INVOICE PAYMENT TYPE S.S.OR I.R.S.IDENT. CHECK AMOUNT
0000000 0/00/00 50 $799 .98
REORDER FT TOI•U.S.PATENT NO.553A29O.TS75588:554 1183,5785353
Interoffice Memo
Date: August 29, 2000
To: Carrie, Cierk Treasurer's Office
From: David Klingensmith, Street Commissioner 4).1.
Re: Board of Works Agenda
Please place the following item on the agenda for the Board
of Public Works and Safety Meeting of September 6, 2000;
1) Release of All Claims - David Klingensmith
I have enclosed original and 8 copies of price letter.
Thank you.
CARMEL STREET DEPARTMENT
211 2 ND St. S. W.
Carmel , IN 46032
Date: August 29, 2000
To: Board of Public Works and Safety
From: David Klingensmith, Street Commissioner N•V,
Re: Release of All Claims
At the September 6, 2000 Board of Public Works and Safety
Meeting, I will be presenting for your signatures a "Release of All
Claims"from an accident that occurred on Hazel Dell Parkway on
January 18, 2000. The insured damaged 2 trees, which have been
replaced and the insurance check deposited into the City's account.
Thank you for your consideration in this matter.