Personal Injury Settlement Agreement - Delaware

Personal Injury Settlement Agreement and Release

Settlement-Control Worksheet

Claim and proceeding

Capacity and approval route

• ☐ Claimant is an adult with capacity and no court, fiduciary, estate, bankruptcy, or other approval requirement was identified.
• ☐ Claimant is a person with a disability within the Rule 133 process, including a person under age 18; complete the Rule 133 Annex.
• ☐ Claimant acts through a guardian, personal representative, trustee, bankruptcy representative, attorney-in-fact, or other fiduciary; authority and approval are documented at [________________________________].
• ☐ Another approval or notice is required: [AUTHORITY, DECISION-MAKER, AND CONDITION].

Released-party schedule

List every intended released person or entity by name or a precise defined relationship. Do not use an unlimited affiliate or family label without confirming who it reaches.

Reserved-claim schedule

Lien, reimbursement, and obligation ledger

Identify each asserted or potential obligation from current records. Do not promise that Claimant is solely responsible until authority, notice, priority, appeal, compromise, and payment instructions have been reviewed.

Funding and disbursement

• Funding party: [________________________________]
• Payment form and payee(s): [________________________________]
• Contractual funding deadline and trigger: [________________________________]
• Settlement proceeds will be held in: [TRUST / ESCROW / COURT-APPROVED ACCOUNT / OTHER].

Dismissal sequence, if an action is pending

• ☐ No action is pending.
• ☐ Claimant may use a Rule 41(a)(1)(I) notice; counsel confirmed its conditions.
• ☐ All parties who appeared will sign a Rule 41(a)(1)(II) stipulation.
• ☐ Court order is required under Rule 41(a)(2) or another rule.
• Dismissal prejudice and claim scope: [________________________________]
• Dismissal document held by: [________________________________]
• Filing trigger: [CLEARED FUNDS / APPROVAL / OTHER].

This Personal Injury Settlement Agreement and Release (the "Agreement") is entered as of [__/__/____] by:

Claimant: [FULL LEGAL NAME], [CAPACITY AND REPRESENTATIVE, IF ANY], of [ADDRESS];

Released Defendant: [FULL LEGAL NAME], [ENTITY TYPE, IF ANY], of [ADDRESS]; and

Funding Party, if different: [FULL LEGAL NAME AND ROLE], of [ADDRESS].

1. Incident and Dispute

1.1 On or about [__/__/____], [DESCRIBE THE INCIDENT WITHOUT EXPANDING THE CLAIM]. The parties dispute [LIABILITY / CAUSATION / DAMAGES / OTHER].

1.2 The pending action, if any, is [CAPTION, COURT, AND CASE NUMBER] (the "Action").

1.3 This Agreement compromises disputed claims. It is not an admission of liability, fault, causation, damages, coverage, or wrongdoing by any person.

2. Settlement Consideration

2.1 In exchange for the release and promises in this Agreement, [FUNDING PARTY] shall provide total consideration of $[GROSS AMOUNT] as follows:

2.2 Structured payments, if selected. The exact issuer, owner, payee, payment dates, guaranteed and life-contingent terms, beneficiary terms, fees, ratings, assignment documents, and funding conditions appear in Exhibit A. No summary in this Agreement overrides Exhibit A. Court approval is a condition only when required by Rule 133, another governing authority, or a court order identified here: [________________________________].

2.3 Payment is timely only when [CLEARED FUNDS / ISSUED CHECK / COMPLETED WIRE / ANNUITY FUNDING] occurs. A party may not change the payee or payment instructions without authenticated written direction accepted by the affected parties.

2.4 No party makes a tax representation in this Agreement. The parties shall use the allocation, reporting, withholding, and information-return treatment approved by their tax advisors and stated in Exhibit B, if any.

3. Conditions and Closing Sequence

3.1 The following must occur before the Release Effective Time:

• all required parties sign this Agreement;
• any Rule 133 or other required approval order is entered and all conditions in it are satisfied;
• the lien and reimbursement schedule is finalized or the agreed holdback is funded;
• agreed payment instructions and required tax forms are delivered;
• structured-settlement documents, if any, are executed and funded as stated in Exhibit A; and
• [OTHER CONDITION].

3.2 Release Effective Time. The release becomes effective only when [ALL SETTLEMENT FUNDS CLEAR / REQUIRED APPROVAL AND FUNDING BOTH OCCUR / OTHER PRECISE EVENT]. Until then, the signed dismissal document shall be held by [ESCROW HOLDER] and shall not be filed.

3.3 If a condition is delayed or fails, the parties shall follow this written notice, cure, extension, return-of-documents, and termination process: [________________________________]. Termination does not create an automatic judgment or revive a dismissed claim except as authorized by a court order or applicable procedure.

4. Claimant's Release

4.1 At the Release Effective Time, Claimant releases only the persons and entities listed in the Released-Party Schedule from claims owned by Claimant that:

• arise out of the Incident described in Section 1.1;
• concern injury, damage, loss, or expense through [CUTOFF DATE / RELEASE EFFECTIVE TIME]; and
• fall within this selected scope: ☐ known claims only ☐ known and unknown claims, after informed review of the consequences.

4.2 The release includes these specifically identified claims: [________________________________].

4.3 The release does not include:

• a claim listed in the Reserved-Claim Schedule;
• a claim owned independently by a person who did not sign this Agreement;
• a promise, payment duty, or enforcement right created by this Agreement;
• a claim arising from conduct after the selected cutoff, except performance of this Agreement; or
• [OTHER EXPRESS EXCLUSION].

4.4 Claimant represents, after reasonable inquiry, that Claimant has not assigned a released claim except as disclosed here: [________________________________].

5. Defendant Release, If Supported

Select one and delete the other:

• No reciprocal release. Defendant gives no release because no supported counterclaim or claimant liability is being settled.
• Defined reciprocal release. At the Release Effective Time, Defendant releases Claimant only from [IDENTIFIED COUNTERCLAIM OR INCIDENT-RELATED CLAIM], excluding [RESERVED MATTERS].

6. Liens, Reimbursement, and Holdbacks

6.1 The parties adopt the completed lien ledger as Exhibit C. Payment duties shall follow final written demands, compromise documents, orders, and authenticated instructions rather than estimates in negotiations.

6.2 [ESCROW HOLDER] may retain $[____] for disputed or unresolved items until [AGREED RELEASE CONDITION]. The holder may pay an item only under [JOINT WRITTEN INSTRUCTION / FINAL DETERMINATION / OTHER]. Any remainder shall be paid to [PAYEE].

6.3 Claimant shall provide truthful information and reasonable cooperation for identified lien and reimbursement resolution. Defendant or the Funding Party shall provide the payment and coverage information identified here: [________________________________].

6.4 Optional narrow indemnity. Claimant indemnifies [IDENTIFIED PARTY] only for [IDENTIFIED LIEN OR REIMBURSEMENT CLAIM] to the extent loss results from Claimant's material breach of the representation in Section [____], excluding amounts caused by the indemnified party's own conduct, failure to follow the agreed holdback, or payment contrary to written instructions. Defense control, notice, settlement authority, and any limit are: [________________________________].

6.5 No blanket indemnity applies to unknown liens, claims already paid from settlement proceeds, or obligations imposed directly on a released or funding party by governing law.

7. Dismissal and Case Filings

7.1 If the Action is pending, [PARTY] shall hold the signed [NOTICE / STIPULATION / PROPOSED ORDER] and file it only after the Release Effective Time and any required approval.

7.2 The dismissal shall be [WITH / WITHOUT] prejudice and shall cover only [CLAIMS / PARTIES]. Counsel shall use the Rule 41 route selected in the worksheet and account for every appeared party, counterclaim, crossclaim, and court order.

7.3 Each party bears its own attorney fees and costs except for the disbursements expressly approved in the settlement schedule or an approval order. This Agreement creates no automatic prevailing-party fee right.

8. Confidentiality and Communications — Optional

Select, narrow, or delete this section.

8.1 The following information is confidential: [SETTLEMENT AMOUNT / NEGOTIATIONS / OTHER]. The fact of the Incident, filed public record, medical information controlled by Claimant, or other excluded information is treated as follows: [________________________________].

8.2 Permitted disclosures include those to tax, legal, financial, medical, and insurance advisors; household members bound to confidentiality; lien and benefits administrators; auditors; regulators; courts; and disclosures required by subpoena, order, or law. Notice before a compelled disclosure is required only when lawful and practicable.

8.3 The confidentiality clause does not prohibit truthful testimony, reporting to government, participation in an investigation, or communication that cannot lawfully be restricted.

8.4 Remedy, causation, proof, and any agreed liquidated amount for a breach are: [________________________________]. No forfeiture of the personal-injury settlement or automatic injunction applies.

9. Representations and Reliance

9.1 Each signing person represents that the person has read the Agreement, had the opportunity for independent legal and financial advice, understands the selected release scope, and signs voluntarily.

9.2 Each fiduciary or representative signs only under the authority and approval identified here: [________________________________]. A parent or guardian signature does not replace Rule 133 approval when that process applies.

9.3 Except for promises written in this Agreement, each party disclaims reliance on a statement by another party about medical prognosis, future expenses, tax treatment, public-benefit eligibility, lien amount, insurance coverage, or investment performance.

9.4 Claimant's current known injuries and treatment status are summarized for release-scope review in Exhibit D. The summary does not warrant future medical outcome.

10. Enforcement

10.1 A party claiming breach shall give written notice describing the breach and requested cure. The cure period, if any, is [____] days, except that failure to fund may use this negotiated process: [________________________________].

10.2 Available contract remedies, judgment procedure, interest, damages, fees, and equitable relief are determined by the Agreement, applicable law, and any approval order. This Agreement does not itself convert an unpaid amount into a judgment, reinstate an action automatically, cap all liability at the Settlement Amount, or guarantee specific performance.

10.3 The forum for an enforcement dispute is [COURT WITH EXISTING JURISDICTION / OTHER COURT AFTER JURISDICTION AND VENUE REVIEW]. No exclusive-county term applies unless written here after that review: [________________________________].

11. General Terms

11.1 This Agreement, its exhibits, and any incorporated approval order are the entire settlement agreement concerning the released claims. A change must be in an authenticated writing signed by the parties whose rights or duties change and approved by the court if required.

11.2 Delaware law governs except to the extent another law controls a particular claim, lien, benefit, tax, insurance, fiduciary, or structured-payment issue.

11.3 If a provision is unenforceable, it may be severed only if doing so does not expand the release, change the consideration, defeat required approval, or materially alter the bargain.

11.4 The Agreement may be signed in counterparts. Electronic signing is used only if each signing party agrees to transact electronically and the parties preserve a complete, attributable record. Authentication method: [________________________________].

11.5 Notices under this Agreement must be sent by [METHOD] to the following addresses and are effective on [DEFINED EVENT]:

Signatures

Claimant or Authorized Representative

Signature: ________________________________

Printed name: [________________________________]

Capacity and authority, if representative: [________________________________]

Date: [__/__/____]

Released Defendant

Signature: ________________________________

Printed name and title: [________________________________]

Date: [__/__/____]

Funding Party, If a Contracting Party

Signature: ________________________________

Printed name and title: [________________________________]

Date: [__/__/____]

Counsel Approval as to Form, If Used

Claimant's counsel: ________________________________ Date: [__/__/____]

Defendant's counsel: ________________________________ Date: [__/__/____]

Rule 133 Approval Annex

Complete this Annex only when Delaware Superior Court Civil Rule 133 applies. Use the current court-required petition, affidavit, proposed order, and filing method; this Annex is a control record, not a substitute for those filings.

A. Threshold and Proposed Disposition

• Person with a disability / minor: [NAME, AGE, AND CAPACITY BASIS]
• Gross settlement, inclusive of costs and attorney fees: $[________________________________]
• Attorney fee: $[________________________________]
• Costs: $[________________________________]
• Subrogation claims and unpaid Incident-related obligations: $[________________________________]
• Net settlement: $[________________________________]

Select the proposed Rule 133 route:

• ☐ Gross amount is $25,000 or less; request approval of net funds in a UTMA account without a property guardian under Rule 133(a)(3).
• ☐ Gross amount exceeds $25,000; request a court-approved annuity or structured financial instrument under Rule 133(a)(4)(i).
• ☐ Gross amount exceeds $25,000; request no more than $25,000 in a UTMA account and the balance in a court-approved annuity or structured financial instrument under Rule 133(a)(4)(ii).
• ☐ Request appointment of a guardian of property under Rule 133(a)(5). If all net funds would otherwise qualify under Rule 133(a)(3) or (a)(4), state the Rule 133(a)(5)(ii) good-cause and best-interests basis.

B. Petition Evidence and Hearing Track

• ☐ Petition is supported by an affidavit consistent with current Form Rule 133B.
• ☐ Medical reports, affidavits, and other fairness evidence are attached.
• ☐ Non-petitioning parent's consent affidavit is attached.
• ☐ Consent cannot be obtained; petitioner's affidavit explains why.
• ☐ Gross proceeds are less than $50,000; papers-only route requested unless the Court orders otherwise.
• ☐ Gross proceeds are $50,000 or more; open-court hearing planned with the person present unless otherwise ordered.
• ☐ Petition and accompanying documents are filed under the Rule 133(g) seal procedure.

C. Annuity, UTMA, or Guardianship Controls

• ☐ Proposed UTMA order is consistent with current Form Rule 133A.
• ☐ Proof of the approved annuity or structured instrument will be filed within 60 days after the approval order unless the Court orders otherwise.
• ☐ The final approval order's payment, holdback, fee, cost, account, reporting, and dismissal terms have been inserted into the closing checklist.

Final Closing Checklist

• ☐ Every released party, released claim, reserved claim, and independent nonparty claim is identified.
• ☐ Capacity, fiduciary authority, and Rule 133 or other approval were resolved before release and dismissal.
• ☐ Gross consideration, fees, expenses, liens, holdbacks, net payment, and structured terms reconcile.
• ☐ Payment, release, approval, and dismissal occur in a coherent sequence.
• ☐ The Rule 41 dismissal path fits the procedural posture and every appeared party or counterclaim.
• ☐ No blanket unknown-lien indemnity, settlement-amount liability cap, automatic fee award, automatic judgment, or automatic reinstatement remains.
• ☐ Electronic signatures use agreed and attributable procedures.
• ☐ All drafting notes, unused options, and blank schedules were completed or removed.

Sources and References

• Delaware Superior Court Rules of Civil Procedure — Rules 41 and 133
• August 13, 2025 order amending Rule 133 effective September 1, 2025
• Delaware Uniform Electronic Transactions Act