[Iowa DOT] 181301. Accident Settlement Agreement Release Form

AGREEMENT

IT IS UNDERSTOOD AND AGREED by the parties to this agreement that this agreement DOES NOT serve as compliance to the Iowa Financial Responsibility requirements for the above described accident for any person(s) other than those whose signatures have been notarized hereon.

IT IS FURTHER UNDERSTOOD AND AGREED by the parties to this agreement that upon payment in full of the sum herein specified, the party(s) of the first part shall stand released and forever discharged from any and all claims, causes of action and demands whatsoever, which the party of the second part has or may hereafter have on account of damage, loss or injury resulting from said accident.

IT IS FURTHER UNDERSTOOD AND AGREED as a result of a judgment and this agreement, consent is given to allow driving and/or registration privileges as allowed by law.

TO BE COMPLETED BY PARENT OR GUARDIAN

(If legal guardian, supporting legal documentation must also be submitted for verification).

TO BE COMPLETED BY INSURANCE COMPANY REPRESENTATIVE SIGNING THIS AGREEMENT RELEASE.

for loss sustained resulting from this accident.

ALL SIGNATURES MUST BE NOTARIZED

Additional Signatures Required

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