PERSONAL INJURY SETTLEMENT AGREEMENT AND MUTUAL RELEASE
(State of Georgia)
[// GUIDANCE: Replace all bracketed, bold placeholders with deal–specific information before execution. Remove guidance comments prior to final signature.]
TABLE OF CONTENTS
- DEFINITIONS
- SETTLEMENT PAYMENT & DELIVERY
- MUTUAL RELEASE & DISCHARGE
- REPRESENTATIONS & WARRANTIES
- COVENANTS
- DEFAULT; REMEDIES
- RISK ALLOCATION
- DISPUTE RESOLUTION
- GENERAL PROVISIONS
- EXECUTION BLOCK
- COURT APPROVAL FOR MINOR (IF APPLICABLE)
1. DEFINITIONS
For purposes of this Agreement, capitalized terms have the meanings set forth below. Any term used in the singular includes the plural and vice-versa.
1.1 “Action” means that certain personal-injury matter styled [STYLE OF ACTION], pending in [COURT NAME & DOCKET NO.] (the “Court”).
1.2 “Adjustment Date” means the date the Settlement Amount is first due under Section 2.2.
1.3 “Claim(s)” means any and all past, present, or future claims, causes of action, demands, rights, damages, costs, expenses, compensation, or relief of whatever kind, whether known or unknown, asserted or unasserted, arising out of or relating to the Incident.
1.4 “Effective Date” means the date on which the last Party executes this Agreement.
1.5 “Incident” means the events of [DATE & LOCATION] described in the Action that allegedly caused bodily injury to Releasor.
1.6 “Parties” means, collectively, (a) [FULL LEGAL NAME OF RELEASOR], including his/her/their heirs, representatives, successors, and assigns (“Releasor”), and (b) [FULL LEGAL NAME OF RELEASEE], including its parents, subsidiaries, affiliates, officers, directors, employees, insurers, reinsurers, successors, and assigns (“Releasee”). Each is a “Party.”
1.7 “Settlement Amount” means the total consideration described in Section 2.2, inclusive of all damages, fees, costs, interest, and liens.
1.8 “Structured Payment” means periodic payments, if any, established under Section 2.3.
2. SETTLEMENT PAYMENT & DELIVERY
2.1 Consideration. In consideration of the mutual promises herein, and subject to performance of all conditions precedent, Releasee shall pay (or cause its insurer to pay) the Settlement Amount to Releasor in full satisfaction of the Claims.
2.2 Payment Terms.
(a) Lump-Sum Option. If elected, Releasee shall tender [US $______] (the “Lump-Sum Settlement Amount”) to Releasor within [___] business days after the later of (i) Effective Date, or (ii) receipt by Releasee of an executed Form W-9 and any lien-holder payee information.
(b) Structured Option. If the Parties agree to a structure, payment shall be made in accordance with Section 2.3.
2.3 Structured Settlement (Optional).
(a) Schedule. Releasee shall fund an annuity issuing periodic payments as follows:
| Payment No. | Due Date | Amount (USD) | Payee |
|---|---|---|---|
| 1 | [DATE] | [$] | Releasor |
| … | … | … | … |
(b) Compliance. The Parties intend the structure to comply with the federal Periodic Payment Settlement Act, 26 U.S.C. § 130, and the Georgia Structured Settlement Protection Act, O.C.G.A. §§ 51-12-71 et seq.
(c) Assignment. Releasor shall not assign or transfer Structured Payment rights except as permitted by applicable law and court order.
2.4 Tax Characterization. No Party provides tax advice under this Agreement. Each Party shall seek independent tax counsel regarding the tax consequences, if any, of the Settlement Amount.
2.5 Exclusive Remedy. Payment of the Settlement Amount constitutes the sole monetary remedy for the Claims.
3. MUTUAL RELEASE & DISCHARGE
3.1 Release by Releasor. Upon receipt of the Settlement Amount, Releasor irrevocably releases and forever discharges Releasee from any and all Claims.
3.2 Release by Releasee. Upon Effective Date, Releasee releases Releasor from any contribution or indemnity claims arising from the Incident.
3.3 Scope; Georgia Law. The releases in this Section 3 are intended to be as broad and comprehensive as permissible under O.C.G.A. § 13-3-41 and governing Georgia tort law.
3.4 Unknown Claims. Releasor expressly waives any right to assert unknown or unsuspected Claims.
3.5 No Admission. This Agreement is a compromise settlement and not an admission of liability.
4. REPRESENTATIONS & WARRANTIES
4.1 Authority. Each Party represents it has full authority to execute and perform this Agreement.
4.2 No Assignment. Releasor represents that no portion of the Claims has been sold, assigned, or otherwise transferred.
4.3 Medicare/Medicaid. Releasor represents that (a) Releasor is/ is not a Medicare beneficiary, and (b) no conditional payments remain unpaid. Releasor shall satisfy or resolve all reimbursement obligations under the Medicare Secondary Payer Act, 42 U.S.C. § 1395y(b).
4.4 Competency. Releasor is of legal age and competent, or, if a minor, the settlement is subject to Section 11.
4.5 Survival. The representations and warranties in this Article survive closing for three (3) years.
5. COVENANTS
5.1 Dismissal of Action. Within five (5) business days after receipt of the Settlement Amount (or first Structured Payment), Releasor shall file a stipulation of dismissal with prejudice in the Action.
5.2 Liens. Releasor shall identify and resolve all hospital, medical, workers’ compensation, ERISA, child-support, or governmental liens.
5.3 Confidentiality. The Parties shall keep the terms of this Agreement confidential, except (a) as required by law or court order, (b) to spouses, tax advisors, or insurers, who must honor this confidentiality, or (c) to enforce the Agreement.
5.4 Non-Disparagement. The Parties agree not to make statements intended to harm the reputation of the other regarding the Incident or this settlement.
5.5 Further Assurances. The Parties shall execute and deliver such additional documents as reasonably necessary to effectuate this Agreement.
6. DEFAULT; REMEDIES
6.1 Events of Default. Releasee’s failure to timely pay any portion of the Settlement Amount constitutes an Event of Default.
6.2 Cure Period. Releasee shall have seven (7) calendar days after written notice to cure any monetary default.
6.3 Remedies. Upon an uncured Event of Default, Releasor may:
(a) Accelerate. Declare all unpaid portions of the Settlement Amount immediately due and payable.
(b) Judgment. Seek entry of consent judgment for the unpaid balance plus interest at [___]% per annum, reasonable attorney fees, and costs.
6.4 Limitation. The remedies set forth herein are exclusive absent willful misconduct or fraud.
7. RISK ALLOCATION
7.1 Mutual Indemnification. Each Party (“Indemnifying Party”) shall defend, indemnify, and hold harmless the other Party from any Losses arising out of the Indemnifying Party’s breach of this Agreement or misrepresentation herein.
7.2 Lien Indemnity. Releasor shall indemnify Releasee from any lien, subrogation, or reimbursement claim asserted against Releasee relating to the Claims.
7.3 Limitation of Liability. The liability of each Party under or in connection with this Agreement shall not exceed the Settlement Amount.
7.4 Force Majeure. No Party shall be liable for delay or failure in performance caused by acts of God, war, terrorism, or other events beyond its reasonable control; provided, payment obligations are expressly excluded from force-majeure protection.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Agreement shall be governed by the substantive law of the State of Georgia, without regard to its conflict-of-laws rules.
8.2 Forum Selection. The Parties submit to the exclusive jurisdiction of the state courts of [COUNTY, GEORGIA] for any dispute arising under this Agreement.
8.3 Arbitration & Jury Trial. The Parties expressly waive any requirement to arbitrate and acknowledge that no jury-trial waiver is provided herein.
9. GENERAL PROVISIONS
9.1 Entire Agreement. This document constitutes the entire agreement between the Parties and supersedes all prior negotiations.
9.2 Amendments. No modification is effective unless in a written instrument signed by both Parties.
9.3 Waiver. A waiver of any provision must be explicit and in writing; no course of conduct constitutes a waiver.
9.4 Assignment. Neither Party may assign rights or delegate duties without prior written consent, except Releasee may assign rights to its insurer for payment.
9.5 Severability. Any unenforceable provision shall be reformed to the minimum extent necessary to render it enforceable while preserving intent.
9.6 Headings. Section headings are for convenience only and do not affect interpretation.
9.7 Counterparts; Electronic Signatures. This Agreement may be executed in counterparts, each deemed an original. Signatures transmitted via PDF, DocuSign, or similar electronic means shall be binding to the same extent as originals under O.C.G.A. § 10-12-7.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the Parties have executed this Personal Injury Settlement Agreement and Mutual Release as of the Effective Date.
RELEASOR
Signature: ___
Name: [PRINTED NAME]
Address: [ADDRESS]
Date: ________
RELEASEE
By: ____
Name: [AUTHORIZED SIGNATORY]
Title: [TITLE]
Company: [ENTITY NAME]
Date: ________
[// GUIDANCE: Insert notary block if required by local practice or if minor settlement mandates court-approved, notarized signatures.]
11. COURT APPROVAL FOR MINOR (IF APPLICABLE)
11.1 Conditional Nature. If Releasor is a minor, effectiveness of this Agreement is contingent upon compliance with O.C.G.A. § 29-3-3 and any applicable Probate Court or Superior Court approval.
11.2 Guardian’s Authority. The natural guardian(s) or court-appointed conservator(s) executing this Agreement on behalf of the minor represent that:
(a) The gross settlement value is [STATE AMOUNT];
(b) Court approval is/ is not required under O.C.G.A. § 29-3-3;
(c) All requisite petitions will be filed within [___] days of execution.
11.3 Escrow/Conservatorship. If court approval is required, Releasee shall tender the Settlement Amount into the registry of the approving court or to an approved conservator, as directed by the approval order.
[// GUIDANCE: Attach any required exhibits—e.g., Medicare lien confirmation, structured-settlement schedule, dismissal stipulation—in final package.]