I UNDERSTAND THAT I HAVE THE RIGHT TO CONSULT AN ATTORNEY IF I HAVE ANY QUESTIONS ABOUT ANY OF THE TERMS OF THIS AGREEMENT. Signature:_____________________________________ Date:__________________ Print Name:___________________________________ (Please initial all pages) State of_________________________} County of _______________________} ss._________________________ On this the ____ day of ___________________, 20___, before me, the undersigned authority, personally appeared __________________________________, known to me (or satisfactorily proven) to be the person name is subscribed to the within instrument and acknowledged that he/she executed the foregoing instrument for the purposes therein contained as and for his/her free act and deed. IN WITNESS WHEREOF, I have hereunto set my hand and seal. _____________________________________________________ Notary Public / Commissioner of the Superior Court My commission expires: _________________________________ Page 3 of 3 Initialed___________
I UNDERSTAND THAT I HAVE THE RIGHT TO CONSULT AN ATTORNEY IF I HAVE ANY QUESTIONS ABOUT ANY OF THE TERMS OF THIS AGREEMENT. Signature:_____________________________________ Date:__________________ Print Name:___________________________________ (Please initial all pages) State of_________________________} County of _______________________} ss._________________________ On this the ____ day of ___________________, 20___, before me, the undersigned authority, personally appeared __________________________________, known to me (or satisfactorily proven) to be the person name is subscribed to the within instrument and acknowledged that he/she executed the foregoing instrument for the purposes therein contained as and for his/her free act and deed. IN WITNESS WHEREOF, I have hereunto set my hand and seal. _____________________________________________________ Notary Public / Commissioner of the Superior Court My commission expires: _________________________________ Page 3 of 3 Initialed___________
Travelers%20Immersion%20Release%20of%20Claims%202-1-18.docx