ST9302-CS000714 /~/////. / ~ ~.~, ~,,..~._ _ _ Tracking Number: XD00449
' ///fU./v- Claim Handler: Laura Christian-Crawford
e flltl] LZASZ OF ALL CLA S
Know Ali Men By These Presents, that the Undersigned do(es) hereby acknowledge receipt of a check
for Five Thousand Thirty Two Dollars and 18/100 Cents ($5,032.18) which check is accepted in full
compromise settlement and satisfaction of, and as sole consideration for the final release and discharge of,
all actions, claims and demands whatsoever, that now exist, or may hereafter accrue, against St. Paul
Guardian Insurance Company, Ed Bell Investments and any other person, corporation, association or
partnership charged with responsibility for injuries to the person and property of the Undersigned, and the
consequences flowing therefrom, as the result of an accident, casualty or event which occurred on or
about October 7, 1999 at or near signal light at Heartz Rd./Sandy Lake Rd., Coppell, TX, and for which
the Undersigned claims the said persons or parties are legally liable in damages; which legal liability and
damages are disputed and denied, and;
The Undersigned Warrants, that no promise or inducement has been offered except as herein set forth;
that this Release is executed without reliance upon any statement or representation by the person or
parties released, or their representatives, or physicians, concerning the nature and extent of the injuries
and/or damages and/or legal liability therefor; that the Undersigned is of legal age, legally competent to
execute this Release and accepts full responsibility therefore, and;
The Undersigned Agrees, as further consideration and inducement for this compromise settlement, that it
is a full and final release of all claims and shall apply to all known and unknown and anticipated and
unanticipated injuries and damages resulting from said accident, casualty or event, as well as to those now
known or disclosed.
It is further agreed that the Undersigned will satisfy from the amount paid to the Undersigned shown
above any and all claims, liens and encumbrance, known or unknown, from any providers of medical and
related services, insurers, attorneys, governmental agencies, or others who may claim lien, subrogation, or
other rights with respect to or related to the accident described herein and any injuries or damages
incurred or sustained as a result of it.
It is understood and agreed that the party or parties hereby released, admit no liability to the undersigned
or others, shall not be estopped or otherwise barred from asserting and expressly reserve the right to assert
any claim or cause of action such party or parties may have against the Undersigned or others.
In Witness Whereof,
day of
Signed, sealed and delivered in the presence of
have hereunto set hand and seal the
in the year two thousand and _00
Ken~M. ~l~Director. o of Engineering/Public Works
(L.S.)
(L.S.)
Before me, a Notary Public, for and within the County of
State of "T ~ X a. 5 , this
personally appeared K~ m ~ t' ~ ~ ['~ ~
and ~ ~
CO WOF Da /lo X
, to me known, and
known to me to be the persons named in and who executed the above release, and they acknowledge to
me that they executed the same as their own free act and deed.
Printed in U.S.A. "~-..~.o.~...~3'l OOtOl~, 17, ~ ~[
DALLAS-FT. WORTI-I
BROOKHOLLOW ONE STE 400
2301 E LAMAR BOULEVARD
ARLINGTON TX 76006
CITY OF COPPELL
P.O. BOX 478
COPPELL TX 75019
0630766063
Claim Number:
KK09100704-09T003
Date of Loss:
10/07/99
If you have any questions,
please call:
LAURA CRAWFORD
(817) 323-1469
Check Amount:
$*****'5,032.18
RE: SANDY LAKE ROAD PROJECT # ST 93-02
'meS[Rlul
8140 Rev. 1-95 Printed in U.S.A.
¥~_.-... --.., - ....... ~_ ......-__ .......... .. ......................................................
ST. PAUL FIRE AND MARINE INSURANCE COMPANY 0630766063
lheSl'r Ul ST. PAUL GUARDIAN INSIJRANCE COMPANY
First Bank East Grand Forks
East Grand Forks, MN 56721
Date: 07/12/00 ^cct. No. 75-1592
Claim Number: KK00100704-00T003 I01 01'2
CFI~' OF GOPPELL :$*****'5,0~2.18
' DOLLARS
By Authorized Represen 'ye
P.O. BOX 478
COPPELL TX 75010
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