Waiver And Consent For Insurance Company {WD-5}

Form WD-5 (Waiver and Consent for Insurance Company) NOTE: If the action was settled with the assistance of the Supreme Court, or if the amount of the settlement has been otherwise approved, this form will not be required. SURROGATE'S COURT OF THE STATE OF NEW YORK COUNTY OF In the Matter of the Application of as Administrat of the Goods, Chattels and Credits which were of , deceased, 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_______. TO THE SURROGATE'S COURT: The___________________________________Insurance Company, with offices at ____________________________________________________________________________ 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:________________________ ____________________Insurance Company BY: STATE OF NEW YORK COUNTY OF ) )ss:. WAIVER AND CONSENT FOR INSURANCE COMPANY FILE # ________________ On the ___________ day of ________________________, 20____, 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 Commission Expires: (Affix Stamp) American LegalNet, Inc. www.FormsWorkFlow.com