Personal Injury Settlement Agreement - District of Columbia
PERSONAL INJURY SETTLEMENT AGREEMENT AND MUTUAL RELEASE
District of Columbia
This Agreement is made on [__/__/____] between [CLAIMANT FULL LEGAL NAME], of [ADDRESS] (Claimant), and [RESPONDENT FULL LEGAL NAME], of [ADDRESS] (Respondent). The parties refer to the incident on [__/__/____] at [LOCATION], described as [BRIEF DESCRIPTION] (Incident). Respondent disputes liability. The parties settle the claims identified below without an admission of fault.
1. Settlement payment
Respondent shall pay $[AMOUNT] (Settlement Amount) by [CHECK / WIRE] to [PAYEE AND PAYMENT INSTRUCTIONS] within [NUMBER] business days after all conditions in Section 2 are met. Payment is complete when funds are received and available to the designated payee. The payment instructions and any approved holdback are stated in Schedule A.
If periodic payments are agreed, Schedule A must identify each payment amount and date, the funding party, any annuity or assignment documents, and the person entitled to receive payment. No periodic-payment arrangement is created by leaving Schedule A blank.
2. Conditions before payment or release
Claimant capacity and approval. Claimant is [AN ADULT SIGNING FOR SELF / A MINOR REPRESENTED BY THE SIGNER BELOW / AN ADULT SIGNING THROUGH AN AUTHORIZED REPRESENTATIVE]. Identify the representative and attach evidence of authority: [DETAILS / NOT APPLICABLE].
If this settlement concerns a minor in a pending action, a judge of the court where that action is pending must approve it under D.C. Code § 21-120(a). If the net money and property due the minor after fees, costs, and related expenses exceeds $3,000, a person receiving it for the minor must first be appointed and qualified as guardian of the minor's estate under § 21-120(b). List the action, order, guardian, and permitted payment recipient here: [COURT / CASE / ORDER / GUARDIAN / ACCOUNT OR NOT APPLICABLE].
For a minor without a pending action or an adult whose capacity or representative authority is in question, list the applicable approval and payment authority obtained for this settlement: [AUTHORITY AND DOCUMENTS / NOT APPLICABLE]. No release or dismissal for that claimant takes effect until the listed required authority and approval have been obtained.
Recovery interests. The parties shall complete Schedule B with each known asserted lien, reimbursement claim, or other payment interest, its holder, the amount asserted, and the agreed payoff, holdback, direct payment, or dispute procedure. A listed claim is not admitted merely because it is listed. If Medicare made conditional payments for Incident-related care, the parties shall identify the reimbursement record and resolve any demonstrated responsibility to reimburse under 42 U.S.C. § 1395y(b)(2)(B)(ii). This Agreement does not purport to discharge a government or other third party's independent claim.
3. Releases
Upon completion of Section 2 and receipt of the Settlement Amount under Section 1, Claimant releases Respondent and only the additional persons or entities named here: [NAMES / NONE] (Released Parties), from Claimant's claims arising out of the Incident, whether presently known or later discovered. The release includes [IDENTIFY CLAIM TYPES OR "ALL CLAIMS OWNED BY CLAIMANT ARISING FROM THE INCIDENT"].
At the same time, Respondent releases Claimant from Respondent's claims arising out of the Incident, except obligations under this Agreement. No person who has not signed this Agreement releases an independent claim. The parties reserve claims against nonsettling persons as follows: [RESERVATIONS / NONE STATED]. This Agreement does not determine contribution or credit rights of a person who is not a party to it.
The releases do not discharge any party's duties under this Agreement or the payment and holdback instructions in Schedules A and B. If payment does not occur, no release arises solely from signing.
4. Pending action
Pending action, if any: [COURT, CASE NUMBER, CAPTION / NONE]. After payment and any required approval, the parties shall file [AGREED DISMISSAL DOCUMENT] by [DATE OR NUMBER OF BUSINESS DAYS], with [ALLOCATION OF COURT COSTS]. They shall not file a dismissal before satisfying any court approval required by Section 2.
5. Taxes and representations
Each party shall obtain its own tax advice and make filings required of it. This Agreement makes no representation that any portion of the Settlement Amount is excluded from income or qualifies for a particular tax treatment.
Each signer represents that the signer has authority to enter this Agreement, that no claim being released has been assigned except as disclosed here: [DISCLOSURES / NONE], and that the signer has had an opportunity to review the Agreement with counsel. An assignment or asserted recovery interest disclosed in Schedule B is governed by the agreed procedure there.
6. Optional confidentiality
☐ Elected: The parties shall keep the Settlement Amount and terms confidential except for disclosures to counsel, tax advisers, insurers, auditors, persons administering payment or recovery interests, as required by law or court order, or to enforce this Agreement.
☐ Not elected: No contractual confidentiality duty is created.
7. Enforcement and general terms
A party may seek the remedies available under applicable law for breach of this Agreement. The parties make no contractual waiver of jury rights or statutory remedies, no blanket indemnity for third-party claims, and no cap on liability under this Agreement. Each party bears its own enforcement fees and costs unless a court orders otherwise or the parties sign a separate fee provision.
District of Columbia law governs this Agreement. A dispute may be brought in a court with jurisdiction. Changes must be in a writing signed by both parties. If a provision is unenforceable, the remaining provisions continue to the extent they can operate consistently with the settlement. This Agreement, including completed Schedules A and B, is the entire agreement about the Incident.
8. Signatures
CLAIMANT / AUTHORIZED REPRESENTATIVE
Signature: ______________________________ Date: [__/__/____]
Printed name: [NAME] Capacity, if representative: [CAPACITY / NOT APPLICABLE]
RESPONDENT / AUTHORIZED REPRESENTATIVE
Signature: ______________________________ Date: [__/__/____]
Printed name: [NAME] Title, if entity: [TITLE / NOT APPLICABLE]
Schedule A — Payment and holdback instructions
Amount due: $[AMOUNT]. Payee: [NAME]. Method and details: [DETAILS].
Holdback or direct payment, if any: [AMOUNT, HOLDER, RELEASE CONDITION / NONE].
Periodic-payment terms and funding documents, if any: [DETAILS / NONE].
Schedule B — Asserted recovery interests
| Holder and claimed basis | Amount asserted | Payoff, holdback, direct payment, or dispute procedure |
|---|---|---|
| [NAME / NONE] | $[AMOUNT] | [PROCEDURE] |
| [NAME / NONE] | $[AMOUNT] | [PROCEDURE] |
Additional supporting records: [LIST / NONE].
About this template
- Last updated
- October 14, 2026
- Citations checked
- October 14, 2026
- Jurisdiction
- District of Columbia
- Category
- Personal Injury
Legal authority
- D.C. Code § 21-120(a)-(b) (minor settlement in pending action)
- 42 U.S.C. § 1395y(b)(2)(B)(ii) (Medicare conditional-payment reimbursement)
Personal injury cases are brought by people who were hurt because of someone else's carelessness: car crashes, slip and falls, defective products, and more. Demand letters, settlement agreements, and court filings in these cases have to document the injuries, the medical treatment, the lost income, and the exact legal basis for holding the other side responsible. Well-prepared paperwork is what drives higher settlements and forces insurers to take the claim seriously.
Not legal advice
This template is provided for informational purposes. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
A reviewer verified this template's legal citations against the official source on October 14, 2026.
D.C. Code § 21-120(a)-(b) (checked October 14, 2026): "A person entitled to maintain or defend an action on behalf of a minor child, including an action relating to real estate, is competent to settle an action so brought and, upon settlement thereof or upon satisfaction of a judgment obtained therein, is competent to give a full acquittance and release of all liability in connection with the action, but such a settlement is not valid unless approved by a judge of the court in which the action is pending."
D.C. Code § 21-120(b) (checked October 14, 2026): "A person may not receive money or other property on behalf of a minor in settlement of an action brought on behalf of or against the minor or in satisfaction of a judgment in the action, where, after deduction of fees, costs and all other expenses incident to the matter, the net value of the money and property due the minor exceeds $3,000, before he is appointed by a court of competent jurisdiction as guardian of the estate of the minor to receive the money or property, and qualifies as such."
42 U.S.C. § 1395y(b)(2)(B)(ii) (checked October 14, 2026): "Subject to paragraph (9), a primary plan, and an entity that receives payment from a primary plan, shall reimburse the appropriate Trust Fund for any payment made by the Secretary under this subchapter with respect to an item or service if it is demonstrated that such primary plan has or had a responsibility to make payment with respect to such item or service."
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