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312.775.7837 tel800.231.8506 fax
Mindy.Eades@esis.com
                • Mindy Eades
                • Claims Examiner

RELEASE OF PROPERTY DAMAGE CLAIM

That the Undersigned as a representative of A. R. Group, being of lawful age, for sole consideration of One Thousand, Five Hundred Twenty-Two Dollars and Twenty-Six Cents ($1,522.26) to the undersigned in hand paid, receipt whereof is hereby acknowledged, do hereby and for my heirs, executors, administrators, successors and assigns release, acquit and forever discharge, Kone, Inc., , Old Republic Insurance Company and ESIS Claims, their agents, servants, successors, heirs, executors, administrators and all other persons, firms, corporations, associations or partnerships 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 or which may hereafter accrue on account of or in any way growing out of any and all known and unknown, foreseen and unforeseen  property damage  and the consequences thereof resulting or to result from the accident, casualty or event which occurred on or about the 4th day of September 2009 at or near Chelsea in Michigan. It is understood and agreed that this settlement is the compromise of a doubtful and 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 released parties deny liability and intend merely to avoid litigation and buy their peace.  CLAIM # 59837303922534

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 terms of this Release are contractual and not a mere recital.

THE UNDERSIGNED HAS READ THE FOREGOING RELEASE AND FULLY UNDERSTANDS IT.

Signed, sealed and delivered this _________ day of ______________________, 2010.

CAUTION: READ BEFORE SIGNING BELOW

WITNESS(ES):       SIGNATURE(S):

___________________________   ___________________________

Witness       Signature – Rep of A.R. Group

___________________________   ___________________________

Witness       Signature –

NOTARY:

State of _______________________ County of ________________________ SS

On this _________ day of _______________________ 2010, before me appeared

_______________________________________________________________________

who is known to be the person(s) named herein and who voluntarily executed this release.

______________________________   _____________________________

Notary Signature      Date Commission Expires

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