CL39 (052019) Final Release Page 1 of 1
Final Release
Return To ICBC
PO BOX 2121, STN TERMINAL
VANCOUVER BC V6B 0L6
Fax 1-877-686-4222
CLAIM NUMBER ADJUSTER NAME ADJUSTER NUMBER PHONE NUMBER TOLL FREE PHONE
ADDITIONAL CLAIM NUMBER(S)
In consideration of the payment of, or the promise to pay, the sum of
Dollars
and Cents ($ ).
Which is directed by the undersigned to be paid as follows:
$
$
$
$
$
The undersigned, for themselves, their heirs, executors, administrators, successors and assigns, hereby release and forever discharge
from any and all actions, causes of action, claims and demands for or by reason of any damage, loss or injury, to person and property
which heretofore has been or hereafter may be sustained in consequence of
EVENT & LOCATION OF LOSS DATE OF LOSS CLAIM NUMBER
And for the said consideration the undersigned agree not to make claim or take proceedings against any other person or corporation
who might claim contribution or indemnity under the provisions of any statute or otherwise.
The undersigned agree that the said payment is not deemed to be an admission of liability on the part of
And it is hereby declared that the terms of this settlement are fully understood; that the amount stated herein is the sole consideration of
this release and that the said sum is accepted voluntarily for the purpose of making a final compromise, adjustment and settlement
of claims for injuries, losses and damages resulting or to result from the said accident.
Signed at this
day of
,
.
Signed in the presence of Read Before Signing
WITNESS SIGNATURE CLAIMANT SIGNATURE
WITNESS NAME (please print) CLAIMANT NAME (please print)
ADDRESS CLAIMANT SIGNATURE
CLAIMANT NAME (please print)
