N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VII, subch. A, Surrogate's Forms, 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

Notes

N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VII, subch. A, Surrogate's Forms, form WD-5