Free MV3041 Release of Liability - Wisconsin

RELEASE OF LIABILITY
MV3041 2/2009 Ch. 344 Wis. Stats.

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Wisconsin Department of Transportation Uninsured Motorist Unit PO Box 7983 Madison WI 53707-7983 File No. SR ­

Uninsured DRIVER Name and Address Uninsured OWNER Name and Address Accident Location Accident Date

The undersigned, for valuable consideration between the parties, receipt of which is acknowledged, does release and forever discharge the uninsured driver and uninsured owner identified above, from any and all claims or causes of action which the undersigned now has or may have because of the motor vehicle accident which occurred at the location and on the date given above. It is understood and agreed that this settlement may be a compromise of a doubtful and disputed claim and that the consideration exchanged is not to be construed as an admission of liability on the part of the parties released. It is also understood that this release discharges all liability between the undersigned and the parties named only. The parties expressly reserve the right to pursue other claims or causes of action against all others who are or may be liable in the above accident.

RELEASING PARTIES

(Witness Signature)

(Print or Type Name of Releasing Party) (Signature) (Date)

(Witness Signature)

(Print or Type Name of Releasing Party) (Signature) (Date)

(Name of Insured) State of (Insurance Company Name ­ If Applicable) (Insurance Company Representative Signature) (Date)

(Date) )

) ss. County ) On the above date, this instrument was acknowledged before me by the named person(s).

Print Form

(Signature, Notary Public) (Print or Type Name, Notary Public)

This release must be witnessed OR notarized.
(Date Commission Expires)