DAR-LIENS, INC. EXCESS MEDICAL PAYMENT FORM

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Customer agrees that the liability of Dar-Liens, Inc., its agents and employees, in connection with services hereunder to the Customer and to all persons having contractual relationships with them, resulting from any acts, errors and/ or omissions, whether negligent or otherwise, of Dar-Liens, Inc., its agents and/or employees is limited to the total fees actually paid by the Customer to Dar-Liens, Inc., for those services.