Form WD-5 - Waiver and consent for insurance company
Form WD-5
(Waiver and Consent for Insurance Company)
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF ________
________x
In the Matter of the Application of
________, as Administrat________ of the Goods,
Chattels and Credits which were of
________ WAIVER AND CONSENT
Deceased, File No. ________
for leave to compromise a certain cause of action for wrongful death of the decedent and to render and have judicially settled an account of the proceedings as such administrat________.
________x
TO THE SURROGATE'S COURT:
The ________ Insurance Company, with offices at ________, New York, as the insurer of ________ and pursuant to its obligations to its insured under said liability insurance policy, does hereby appear and waive issuance and service of a citation in the above entitled proceeding. It further consents to pay the sum of $ ________ in full settlement of the claim for wrongful death of ________, deceased. It further consents that the filing of a bond or other security be dispensed with and waive any further notice.
Dated: ________, 19________
INSURANCE COMPANY
By: ________
STATE OF NEW YORK )
) ss.:
COUNTY OF ________ )
On the ________ day of ________, 19 ________, before me personally came and appeared ________, known to me to be a Corporate Officer of the ________ INSURANCE COMPANY, to wit, ________, who had the authority and who did execute the foregoing Waiver and Consent on behalf of the ________ INSURANCE COMPANY and acknowledged that ________executed the same.
______________
Notary Public