Agreement made ______________________, 20___, between _____________________________________________________of _________________________________,herein referred to as the claimant, and the Vermont Bar Association, herein referred to as the Association.
            In consideration of the sum of ____________________________________________Dollars ($___________) paid to the claimant by the Association for loss sustained by the claimant by reason of embezzlement, conversion, or theft by _________________________ ________________________the claimant assigns and subrogates to the Association all rights, claims and rights of action that the claimant may have against any person, corporation or other entity that may be liable for the loss.
            The claimant authorized the Association to sue, compromise or settle in the claimant’s name and agrees to testify and otherwise assist in any proceeding that may be brought to recover the loss.
            The claimant warrants that no settlement has been made with any third party.
            The claimant does acknowledge that he has read the resolution establishing the Clients’ Security Fund, as amended September 5, 2003, and does hereby certify that the above claim is made in accordance with said resolution and the by-laws adopted by the Clients’ Security Fund Committee.
            Executed on the date first written above.
Vermont Bar Association