Free 53845.pdf - Indiana

STATE-OWNED VEHICLES PASSENGER WAIVER OF LIABILITY
State Form 53845 (1-09)

Department of Administration

INSTRUCTIONS:

1. Complete this form before a non-state employee may be a passenger in a state-owned or leased vehicle. 2. Form is to be kept with the vehicle during the time in which travel occurs.

A. RELEASE AND WAIVER OF LIABILITY: I, for myself, my heirs, next of kin, personal representatives and assigns, hereby release, waive, discharge, and covenant not to sue the State of Indiana, its officers, officials, agencies, employees, its successors and assigns (individually and collectively "the State") from all liability, loss, claims, demands, possible causes of action, court cost, attorneys' fees and other expenses arising from lawsuit that may otherwise accrue from any loss, damage or injury (including death) to my person or property in any way resulting from, or arising in connection with, or related to, any authorized use of or travel in a State-owned vehicle, and whether arising during pursuit of State business or personal frolic, or while upon, arrival or departure of State property, from any cause whatsoever including, without limitation, the failure of anyone to enforce rules and regulations, failure to make inspections, or the negligence of other persons. B. ASSUMPTION OF RISK: I know the risk and danger to myself and property, both from known risk and unanticipated risk, while traveling in a State-owned vehicle, and I do so willingly, voluntarily and in reliance, not upon the property furnished by the State, but upon my own judgment and ability, and I thereby assume all risk of loss, damage or injury (including death) to myself and my property from any cause whatsoever and whether or not attributable to the negligence of the State or others. C. INDEMNITY AGREEMENT: I hereby agree to indemnify and hold harmless the State from loss, liability damage or cost, including attorneys' fees and costs of litigation, it may incur due to the presence of the undersigned in or about the State-owned vehicle, whether caused by negligence of the State or otherwise. By signing, I acknowledge I have read, understand and voluntary consent to all statements made above.

SIGNATURE: ___________________________________________ NAME PRINTED: ________________________________________ DATE: ______________________________ WITNESS: ______________________________________________