The following template is provided for educational and drafting-support purposes only and does not constitute legal advice. Parties should consult licensed Arizona counsel before use or execution.
PERSONAL INJURY SETTLEMENT AGREEMENT
AND MUTUAL RELEASE
(Arizona)
[// GUIDANCE: Replace all bracketed material with deal-specific information. Remove guidance comments in final execution copy.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Settlement Payment & Consideration
- Representations & Warranties
- Covenants & Restrictions
- Default; Remedies
- Mutual Release & Indemnification
- Structured Settlement Provisions (if elected)
- Minor Settlement Approval (if applicable)
- Medicare & Lien Resolution
- Dispute Resolution; Governing Law
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Parties.
This Personal Injury Settlement Agreement and Mutual Release (the “Agreement”) is entered into by and between:
(a) [CLAIMANT LEGAL NAME], [an individual | a minor], residing at [ADDRESS] (“Claimant”); and
(b) [DEFENDANT/RELEASEE LEGAL NAME], a [STATE] [entity type], with its principal place of business at [ADDRESS], together with its past, present, and future parents, subsidiaries, affiliates, insurers, reinsurers, officers, directors, managers, employees, agents, representatives, successors, and assigns (collectively, “Releasees”).
[// GUIDANCE: Add additional parties such as insurer, third-party administrator, etc., as needed.]
1.2 Recitals.
A. On or about [DATE], an incident occurred at [LOCATION] resulting in bodily injury to Claimant (the “Incident”).
B. Claimant has asserted or may assert claims against Releasees arising out of or relating to the Incident (the “Action”).
C. The Parties desire to fully and finally resolve all Claims (as defined below) without admission of liability and to avoid the expense and uncertainty of litigation.
D. In consideration of the mutual promises herein, the sufficiency of which is acknowledged, the Parties agree as follows.
1.3 Effective Date; Governing Law.
The “Effective Date” shall be the date on which this Agreement is executed by all Parties or, where court approval is required, the date of entry of the approving order (see Section 9). This Agreement is governed by and construed in accordance with the laws of the State of Arizona without regard to conflicts-of-law principles.
2. DEFINITIONS
For ease of reference, the following capitalized terms have the meanings set forth below and apply equally to singular and plural forms.
“Action” – the civil action, claim, or potential claim concerning the Incident.
“Agreement” – this Personal Injury Settlement Agreement and Mutual Release.
“Claimant” – the party identified in Section 1.1(a).
“Claims” or “Released Claims” – any and all past, present, or future claims, demands, causes of action, damages, costs, losses, expenses, liens, and liabilities of every kind whatsoever, whether known or unknown, suspected or unsuspected, fixed or contingent, in law or equity, arising out of or relating to the Incident.
“Court” – a court of competent jurisdiction in the State of Arizona.
“Effective Date” – defined in Section 1.3.
“Medicare Secondary Payer Laws” – collectively, 42 U.S.C. §1395y(b), applicable regulations, and CMS guidance.
“Minor” – an individual who has not reached the age of majority under Arizona law.
“Parties” – Claimant and Releasees, collectively.
“Settlement Amount” – the consideration described in Section 3.1.
“Structured Settlement” – a settlement providing for periodic payments funded through an annuity or similar financial product and subject to Arizona’s structured settlement protection requirements.
3. SETTLEMENT PAYMENT & CONSIDERATION
3.1 Settlement Amount.
Releasees shall pay to Claimant the total sum of [${USD}] (the “Settlement Amount”), allocated as follows:
(a) Indemnity/Personal Injury: [${}]
(b) Past Medical Expenses: [${}]
(c) Reimbursement of Liens: [${}]
(d) Attorney Fees & Costs: [${}]
[// GUIDANCE: Insert detailed payment schedule and wiring instructions. If structured settlement elected, cross-reference Section 8.]
3.2 Timing of Payment.
Except as otherwise provided herein, Releasees shall tender payment within [__] business days after (i) receipt of a fully executed Agreement, (ii) delivery of a completed IRS Form W-9 for Claimant’s counsel, and (iii) satisfaction of all conditions precedent in Section 3.3.
3.3 Conditions Precedent.
(a) Delivery of a duly executed, court-approved Order (if required under Section 9);
(b) Receipt of executed lien affidavits and hold-harmless agreements (see Section 10);
(c) Receipt of properly completed settlement documents, including a Stipulation for Dismissal with prejudice (if litigation is pending).
3.4 Tax Treatment.
Claimant acknowledges that Releasees make no representations regarding the tax consequences of this settlement. Claimant shall be solely responsible for any federal, state, or local taxes that may be owed, except to the extent arising from Releasees’ failure to timely issue payment.
3.5 Liquidated Damages for Late Payment.
If Releasees fail to timely make payment after satisfaction of the conditions precedent, Releasees shall owe simple interest at [__]% per annum on the unpaid balance until paid in full.
4. REPRESENTATIONS & WARRANTIES
4.1 Mutual Authority.
Each Party represents that it has full power and authority to enter into and perform this Agreement and that the individual signing on its behalf is duly authorized.
4.2 Claimant Reps.
(a) Claimant is the sole owner of the Claims and has not assigned or transferred them.
(b) Except for the liens disclosed in Section 10, no liens or subrogation interests exist.
(c) If Claimant is a Minor, the person signing on the Minor’s behalf is the Minor’s duly appointed parent, guardian, or conservator, empowered to bind the Minor subject to Court approval.
4.3 Releasees Reps.
Releasees deny liability but represent that they have sufficient financial capacity to satisfy the Settlement Amount.
4.4 Survival.
All representations and warranties survive the Effective Date and are not merged into the execution or performance of this Agreement.
5. COVENANTS & RESTRICTIONS
5.1 No Future Claims.
Claimant covenants not to sue Releasees on any Released Claims and agrees to defend and hold Releasees harmless from any future action brought contrary to this covenant.
5.2 Confidentiality.
Except as required by law, subpoena, tax filing, or lien resolution, Claimant and Claimant’s counsel shall keep the terms of this Agreement confidential. A breach of confidentiality shall constitute a material default subject to Section 6.
[// GUIDANCE: Delete or modify confidentiality clause if Parties intend the settlement to be public.]
5.3 Non-Disparagement.
Claimant shall refrain from any statement, written or oral, that disparages Releasees regarding matters arising out of the Incident.
6. DEFAULT; REMEDIES
6.1 Events of Default.
(a) Failure of Releasees to timely pay the Settlement Amount;
(b) Breach of confidentiality or non-disparagement by Claimant;
(c) Material misrepresentation in Section 4.
6.2 Notice & Cure.
The non-defaulting Party shall provide written notice specifying the default. The defaulting Party shall have [10] business days to cure, except that confidentiality breaches are not curable.
6.3 Remedies.
(a) Specific Performance and/or entry of judgment for unpaid amounts plus interest;
(b) Recovery of reasonable attorney fees and costs incurred in enforcement;
(c) Injunctive relief to enforce confidentiality or non-disparagement.
7. MUTUAL RELEASE & INDEMNIFICATION
7.1 Mutual Release.
(a) Claimant, for consideration received, irrevocably releases and forever discharges Releasees from any and all Released Claims.
(b) Releasees release Claimant from any claims arising out of the filing or prosecution of the Action.
7.2 Scope.
The releases extend to all known or unknown Claims. Claimant expressly waives application of any statute or doctrine that would otherwise limit the release to known Claims.
7.3 Indemnification for Liens & Subrogation.
Claimant shall indemnify, defend, and hold Releasees harmless from any unresolved liens, subrogation interests, or reimbursement obligations asserted against Releasees relating to the Incident, except to the extent arising from Releasees’ breach of this Agreement.
7.4 Liability Cap.
The total aggregate liability of Releasees under this Agreement shall not exceed the Settlement Amount plus any applicable interest for late payment under Section 3.5.
8. STRUCTURED SETTLEMENT PROVISIONS (IF ELECTED)
[// GUIDANCE: Delete this section if payment will be made entirely by lump sum.]
8.1 Election & Terms.
(a) Amount to be structured: [${}];
(b) Obligor/Annuity Issuer: [COMPANY] rated not less than A.M. Best [A-];
(c) Payment schedule: [e.g., $X per month for Y years beginning on DATE].
8.2 Qualified Assignment.
Releasees may assign their periodic payment obligation to a qualified assignment company in compliance with Sections 72 and 130 of the Internal Revenue Code and applicable Arizona structured settlement protection law. Claimant agrees to the assignment and shall look solely to the annuity issuer for periodic payments.
8.3 Non-Acceleration; Non-Transfer.
Periodic payments are non-assignable and non-accelerable except as permitted by applicable Arizona structured settlement protection statutes and a final court order.
9. MINOR SETTLEMENT APPROVAL (IF APPLICABLE)
[// GUIDANCE: Include this section if Claimant is a Minor.]
9.1 Court Approval Requirement.
The Parties acknowledge that any settlement of a Minor’s claim is subject to approval by an Arizona court of competent jurisdiction. This Agreement is contingent on such approval.
9.2 Appointment of Guardian/Conservator.
If none has been appointed, Claimant’s parent or legal custodian shall promptly petition the Court for appointment of a conservator or guardian ad litem as required by Arizona law.
9.3 Safeguarding of Funds.
All net settlement proceeds payable to or for the benefit of the Minor shall be:
(a) deposited into a restricted bank account requiring court order for withdrawal; and/or
(b) used to purchase a Structured Settlement as described in Section 8;
all in accordance with the approving Court’s order.
9.4 Failure to Obtain Approval.
If the Court declines to approve the settlement, this Agreement shall be null and void and no consideration shall be due, unless the Parties otherwise agree in writing.
10. MEDICARE & LIEN RESOLUTION
10.1 Reporting & Compliance.
The Parties shall comply with all Medicare Secondary Payer Laws, including any Section 111 reporting obligations.
10.2 Known Liens.
Claimant’s counsel represents that the following liens have been asserted: [LIST OR “NONE”].
10.3 Hold-Harmless.
Claimant agrees to satisfy or resolve all liens at Claimant’s sole expense and to indemnify Releasees against any lienholder claims, penalties, or interest arising from non-payment.
11. DISPUTE RESOLUTION; GOVERNING LAW
11.1 Governing Law.
This Agreement shall be governed by the substantive laws of the State of Arizona.
11.2 Forum Selection.
Any action arising from or relating to this Agreement shall be brought exclusively in the state courts located in [COUNTY], Arizona. Each Party irrevocably submits to such courts’ jurisdiction.
11.3 Waiver of Jury Trial.
[Not applicable—section intentionally omitted in accordance with metadata.]
11.4 Arbitration.
[Not applicable—section intentionally omitted in accordance with metadata.]
12. GENERAL PROVISIONS
12.1 Entire Agreement.
This Agreement constitutes the entire understanding between the Parties and supersedes all prior negotiations or agreements concerning the subject matter.
12.2 Amendments; Waivers.
No amendment or waiver of any provision is effective unless set forth in a written instrument signed by all Parties. No waiver constitutes a waiver of any other provision or subsequent breach.
12.3 Assignment.
No Party may assign its rights or delegate its obligations without prior written consent of the other Parties, except that Releasees may assign obligations under a Structured Settlement pursuant to Section 8.
12.4 Severability.
If any provision is held unenforceable, the remaining provisions shall remain in full force, and the unenforceable provision shall be reformed to the minimum extent necessary to render it enforceable.
12.5 Successors & Assigns.
This Agreement binds and benefits the Parties and their respective successors and permitted assigns.
12.6 Counterparts; Electronic Signatures.
This Agreement may be executed in multiple counterparts, each deemed an original. Signatures transmitted by facsimile, PDF, or compliant e-signature platform constitute valid and binding signatures.
12.7 Headings.
Section headings are for convenience and do not affect interpretation.
13. EXECUTION BLOCK
IN WITNESS WHEREOF, the Parties have executed this Agreement as of the dates set forth below.
CLAIMANT:
[CLAIMANT NAME]
Date: ___
[If Minor]
[NAME], Parent/Guardian/Conservator for [MINOR NAME]
Date: ___
[NOTARIZATION IF REQUIRED]
State of Arizona )
County of __ )
The foregoing instrument was acknowledged before me on __, 20_, by ________.
Notary Public
My Commission Expires: _______
RELEASEES:
[AUTHORIZED SIGNATORY NAME]
[Title], [COMPANY NAME]
Date: ___
[Additional signature blocks as needed]
[// GUIDANCE:
1. Remove inapplicable sections (Structured Settlement, Minor Approval, etc.) if not relevant.
2. Insert county of venue in Section 11.2.
3. Confirm whether notarization is required by insurer or court order.
4. Attach any exhibits (e.g., payment schedule, court order template, lien list) and cross-reference them appropriately.]