In Consideration of the payment or of the promise of payment to the undersigned of $____________, the undersigned hereby release and forever discharge________________________________ from any and all actions, causes of action, claims and demands, for demands, loss or injury, howsoever arising, which heretofore may have been or may hereafter be sustained by the undersigned in consequence of a motor vehicle accident occurring on or about the_____ day of_______________, 201(x).
And for the said consideration the undersigned further agree not to make any claim or take any proceedings against any other person or corporation who might claim contribution or indemnity under the provisions of the Negligence Act and/or any amendments to or successors thereof from the person or persons discharged by this release.
It is understood and agreed that the said payment or promise of payment is deemed to be no admission whatever of liability on the part of the said_____________________.
In Witness Whereof
the undersigned has executed this release the________ day