When an insurance policy is issued, the insured individual agrees to certain terms and conditions. One of these terms may be that the insurance company has the right to pursue subrogation in the event of a loss. This means that, if another party is responsible for damages covered by the policy, the insurance company has the right to seek reimbursement from that party. A subrogation form can be used to document this agreement and protect both the insurer and the insured in case of a dispute. Here we provide a subrogation form sample for your reference. Please note that this is only an example, and you should consult with an attorney before submitting any legal documents related to subrogation.
You can find details about the type of form you want to prepare in the table. It can show you how long it will need to complete subrogation form sample, what parts you need to fill in and several further specific facts.
| Question | Answer |
|---|---|
| Form Name | Subrogation Form Sample |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Form, Subrogation, nc waiver of subrogation pdf, Waiver |
WORKERS COMPENSATION
WAIVER OF SUBROGATION
REQUEST FORM
Insured Name: |
|
Policy #: |
Name and Address of 3rd party from whom the Waiver of subrogation is being requested:
Specific details of the Job:
Job number:State Date:End Date: Please list specific operations that will be performed:
Please explain the scope of the project:
Specific Location of the job - Street address, city or area, state:
Total payroll for the specific job being performed or total payroll for ongoing jobs: $_____________
Number of Employees involved:
Who is responsible for safety controls on this project? What controls are in place?