PERSONAL INJURY SETTLEMENT AGREEMENT
AND MUTUAL RELEASE
(State of Alaska)
[// GUIDANCE: This template is drafted for use in Alaska (“AK”). Delete any bracketed text and fill all [PLACEHOLDER] fields before execution. Review Alaska court rules for minor approvals and any structured-settlement registration requirements.]
TABLE OF CONTENTS
I. Document Header
II. Definitions
III. Operative Provisions
IV. Representations & Warranties
V. Covenants & Restrictions
VI. Default & Remedies
VII. Risk Allocation
VIII. Dispute Resolution
IX. General Provisions
X. Execution Block
I. DOCUMENT HEADER
1.1 Title. Personal Injury Settlement Agreement and Mutual Release (this “Agreement”).
1.2 Parties.
(a) Plaintiff: [PLAINTIFF FULL LEGAL NAME], individually [and as Parent/Legal Guardian of [MINOR NAME] (the “Minor”)].
(b) Defendant: [DEFENDANT FULL LEGAL NAME].
(c) Insurer (if any): [INSURANCE COMPANY NAME].
Plaintiff, Defendant, and Insurer are collectively the “Parties” and each a “Party.”
1.3 Effective Date. This Agreement shall become effective on the later of (i) the date last signed below or (ii) the date of final court approval under Section 3.4 (the “Effective Date”).
1.4 Recitals.
A. Plaintiff alleges that Defendant’s acts or omissions on or about [DATE OF INCIDENT] in [LOCATION] caused personal injuries (“Incident”).
B. The Parties desire to resolve all Claims (as defined below) arising from the Incident without admission of fault, according to the terms herein.
C. If applicable, the Minor’s settlement must receive approval from an Alaska state court of competent jurisdiction.
D. If applicable, a portion of the consideration will be paid through a Structured Settlement (as defined below) compliant with Alaska law and federal tax requirements.
NOW, THEREFORE, in consideration of the mutual covenants, releases, and payments set forth, the Parties agree as follows.
II. DEFINITIONS
For ease of reference, capitalized terms have the meanings below; singular includes plural and vice-versa.
“Action” means any lawsuit, arbitration, administrative proceeding, or claim related to the Incident.
“Agreement” has the meaning set forth in Section 1.1.
“Claim(s)” means any past, present, or future demands, causes of action, suits, debts, damages, judgments, executions, liabilities, liens, costs, expenses, or rights of indemnity or contribution—whether known or unknown, fixed or contingent—arising out of or related to the Incident or to treatment of injuries allegedly resulting therefrom.
“Court” means the Alaska Superior Court or other court of competent jurisdiction selected for approval or enforcement of this Agreement.
“Defense Counsel” means [DEFENSE COUNSEL FIRM NAME] or any successor counsel representing Defendant.
“Dismissal Documents” means a Stipulation for Dismissal with Prejudice and proposed order, in form acceptable to the Court.
“Effective Date” has the meaning set forth in Section 1.3.
“Liens” means any Medicare, Medicaid, ERISA, workers’ compensation, or private health-care liens or subrogation interests relating to the Incident.
“Payment Schedule” means the lump-sum and/or periodic payments described in Section 3.1 and, if applicable, Exhibit A.
“Released Parties” means Defendant, Insurer, their past and present parents, subsidiaries, affiliates, officers, directors, shareholders, managers, partners, employees, agents, attorneys, successors, and assigns.
“Settlement Amount” means the total consideration payable pursuant to Section 3.1.
“Structured Settlement” means an arrangement for periodic payments compliant with Internal Revenue Code § 130 and applicable Alaska law.
“Unknown Injuries” means injuries, conditions, or damages that are presently unknown or unanticipated but that may later develop from the Incident.
III. OPERATIVE PROVISIONS
3.1 Settlement Amount; Payment Schedule
(a) Lump-Sum Payment. Within [NUMBER] business days after all conditions precedent under Section 3.3 are satisfied, Defendant (or Insurer) shall pay Plaintiff [SETTLEMENT_AMOUNT_IN_DOLLARS] by [WIRE/ACH/CHECK] (“Lump-Sum Payment”).
(b) Structured Payments (Optional). If designated in Exhibit A, Defendant (or Insurer) shall purchase an annuity that funds the periodic payments set forth in Exhibit A.
[// GUIDANCE: Exhibit A should identify the annuity issuer, payment dates, and guaranteed amounts.]
3.2 Delivery of Dismissal Documents
Within three (3) court days after receipt of the Lump-Sum Payment, Plaintiff shall execute and file the Dismissal Documents.
3.3 Conditions Precedent
The following are conditions precedent to Defendant’s payment obligation:
(i) Execution of this Agreement by all Parties;
(ii) Delivery of a completed IRS Form W-9 for each payee;
(iii) Receipt of duly executed Court approval order under Section 3.4 (if required); and
(iv) Plaintiff’s certification that all Liens have been resolved or will be satisfied from the Settlement Amount.
3.4 Minor Settlement Approval (If Applicable)
(a) Court Approval Required. No settlement of a Minor’s Claims shall be binding until approved by the Court pursuant to Alaska Rule 90.2 or successor rule.
(b) Guardian ad Litem. If ordered by the Court, Plaintiff shall petition for appointment of a guardian ad litem to review the settlement’s fairness.
(c) Effect of Non-Approval. If the Court declines to approve the settlement, this Agreement shall be void ab initio and all consideration shall be returned, unless the Parties mutually agree to modify and resubmit the settlement.
3.5 Liens and Medical Expenses
Plaintiff shall be solely responsible for satisfying all Liens. Plaintiff agrees to indemnify and hold harmless the Released Parties from any claim by a government agency or third party asserting an unpaid Lien related to the Incident.
3.6 Medicare/Medicaid Compliance
Plaintiff represents that (i) Plaintiff is ☐ / ☐ not a current Medicare beneficiary, and (ii) Plaintiff has taken reasonable steps to identify and satisfy any Medicare conditional payments. The Parties intend this Agreement to comply with the Medicare Secondary Payer Act.
IV. REPRESENTATIONS & WARRANTIES
4.1 Authority. Each signatory has full authority to bind the Party on whose behalf the signatory acts.
4.2 Capacity. Plaintiff represents that Plaintiff (and, if applicable, the Minor’s guardian) is of sound mind and not under duress or undue influence.
4.3 No Assignment. Plaintiff has not sold, assigned, or otherwise transferred any Claim.
4.4 No Bankruptcy. No Party is in bankruptcy or insolvency proceedings that would affect this Agreement.
4.5 Independent Counsel. Each Party had the opportunity to obtain independent legal advice, and enters this Agreement voluntarily, fully understanding its legal effect.
4.6 Accuracy of Information. The Parties’ representations in any approval petition or lien statement are true and complete.
4.7 Survival. All representations and warranties shall survive the Effective Date.
V. COVENANTS & RESTRICTIONS
5.1 Confidentiality. Except as required by law or Court order, the Parties shall keep the terms of this Agreement confidential.
5.2 Non-Disparagement. The Parties shall not publish or utter any statement intended to disparage another Party regarding the Incident or this settlement.
5.3 No Further Claims. Plaintiff covenants not to commence or prosecute any Claim released herein.
5.4 Further Assurances. Each Party shall execute any additional documents reasonably necessary to carry out this Agreement.
VI. DEFAULT & REMEDIES
6.1 Events of Default.
(a) Failure to pay the Lump-Sum Payment or fund the Structured Settlement on time;
(b) Material misrepresentation of Medicare/Lien information;
(c) Breach of confidentiality or non-disparagement covenants.
6.2 Notice and Cure. The non-defaulting Party shall provide written notice describing the default. The defaulting Party shall have ten (10) business days to cure.
6.3 Remedies. If the default is not cured:
(i) Entry of judgment for the unpaid Settlement Amount plus statutory interest;
(ii) Specific performance; and/or
(iii) Reasonable attorney fees and costs incurred to enforce this Agreement.
VII. RISK ALLOCATION
7.1 Mutual Release.
(a) Effective upon receipt of all consideration, Plaintiff releases and forever discharges the Released Parties from all Claims.
(b) Defendant releases and forever discharges Plaintiff from any claims for costs or fees related to the Action, except as expressly set forth herein.
7.2 Waiver of Unknown Injuries. Plaintiff expressly waives and releases Unknown Injuries, acknowledging the possibility of unknown or latent injuries arising in the future.
7.3 Limitation of Liability. The Released Parties’ aggregate liability for the Incident shall not exceed the Settlement Amount.
7.4 Indemnification Regarding Liens. See Section 3.5.
7.5 Force Majeure. Payment deadlines shall be extended to the extent performance is delayed by an event beyond the reasonable control of the paying Party, provided prompt written notice is given.
VIII. DISPUTE RESOLUTION
8.1 Governing Law. This Agreement shall be governed by the tort and contract laws of the State of Alaska, without regard to conflict-of-laws principles.
8.2 Forum Selection. The Parties consent to exclusive jurisdiction and venue in the state courts of Alaska located in [BOROUGH/COUNTY], Alaska.
8.3 Arbitration & Jury Waiver. The Parties expressly waive any obligation to arbitrate. Nothing herein constitutes a jury waiver.
8.4 Equitable Relief. The Parties acknowledge that breach of Sections 5.1 or 5.2 would cause irreparable harm; the non-breaching Party may seek injunctive relief in addition to other remedies.
IX. GENERAL PROVISIONS
9.1 Amendment; Waiver. No amendment or waiver binds any Party unless in a writing signed by all Parties. A waiver on one occasion is not a waiver of any subsequent breach.
9.2 Assignment. No Party may assign rights or delegate duties under this Agreement without prior written consent of the other Parties, except that Defendant or Insurer may assign its payment obligation to a qualified assignment company in connection with a Structured Settlement.
9.3 Severability. If any provision is held invalid, the remainder shall remain enforceable, and the invalid provision reformed to the minimum extent necessary to make it valid.
9.4 Integration. This Agreement (including exhibits) constitutes the entire understanding and supersedes all prior agreements relating to the Incident.
9.5 Successors and Assigns. This Agreement binds and inures to the benefit of each Party’s successors, assigns, heirs, executors, and administrators.
9.6 Headings; Construction. Headings are for convenience only and do not affect interpretation. No presumption shall arise against the drafter.
9.7 Counterparts; Electronic Signatures. This Agreement may be executed in counterparts, all of which together constitute one instrument. Signatures transmitted by facsimile, PDF, or compliant e-signature platform are deemed originals.
X. EXECUTION BLOCK
IN WITNESS WHEREOF, the Parties have executed this Agreement as of the dates set forth below.
PLAINTIFF
Signature: ______
Name: [PLAINTIFF NAME]
Date: _____
If Minor Involved
Signature (Parent/Guardian): ______
Name: [PARENT/GUARDIAN NAME], as Parent/Guardian of [MINOR NAME]
Date: _____
DEFENDANT
Signature: ______
Name: [AUTHORIZED SIGNATORY NAME]
Title: [OFFICER TITLE]
Entity: [DEFENDANT LEGAL NAME]
Date: _____
INSURER (if executing)
Signature: ______
Name: [AUTHORIZED SIGNATORY NAME]
Title: [OFFICER TITLE]
Entity: [INSURANCE COMPANY NAME]
Date: _____
NOTARY ACKNOWLEDGMENT (optional; complete if desired or if required by Court)
State of Alaska )
: ss.
[Judicial District] )
On this _ day of _, 20__, before me personally appeared ___, to me known and known to be the individual(s) described herein and who executed the foregoing instrument, and acknowledged that he/she/they executed the same as his/her/their free and voluntary act.
Notary Public in and for Alaska
My commission expires: ___
Exhibit A – Structured Settlement Payment Schedule
[Attach detailed annuity schedule, issuer information, and assignment documents.]
[// GUIDANCE: File Exhibit A under seal if confidentiality is required.]
[// GUIDANCE: 1) Confirm no Medicare Set-Aside is required. 2) Verify Alaska’s Minor settlement petition format (often includes verified petition, medical report, and proposed order). 3) Update any statutory references once confirmed.]