Personal Injury Settlement Agreement - Indiana

PERSONAL INJURY SETTLEMENT AGREEMENT

Before use: This agreement is for a claimant signing personally as an adult. Identify each person released and each known reimbursement or lien claim before signing.

This Agreement is made on [__/__/____] between:

• Claimant: [CLAIMANT FULL LEGAL NAME], address [________________________________]; and
• Settling Party: [SETTLING PARTY FULL LEGAL NAME], address [________________________________].

The parties resolve the claim arising from the incident described below. Settlement is a compromise and is not an admission of fault.

1. Incident and scope

1.1 Incident date and location: [__/__/____], [________________________________].

1.2 Description of incident and claimed injuries: [________________________________].

1.3 Pending case, if any: [COURT], Cause No. [________________________________]. If no case is pending, write “none”: [________________________________].

1.4 Persons and entities to be released in addition to the Settling Party, if any: [LIST EACH BY NAME AND CAPACITY OR WRITE “NONE”]. These are the “Released Persons.”

1.5 Claims expressly reserved by Claimant: [DESCRIBE OR WRITE “NONE”]. This Agreement does not settle any claim against a person who is not named as a Released Person.

2. Payment

2.1 The Settling Party shall pay Claimant $[________________________________] by [PAYMENT METHOD] no later than [__/__/____]. Payment shall be delivered to [PAYEE AND ADDRESS OR ACCOUNT INSTRUCTIONS].

2.2 Any payment allocated to a disclosed lienholder, reimbursement claimant, or escrow shall be made only as stated in Schedule A, signed by both parties. If no amount is allocated, write “none” in Schedule A.

2.3 If payment is not made as required, the release in Section 3 does not become effective. Claimant may seek payment or other relief available under this Agreement and applicable law.

3. Release

3.1 Upon receipt of the full cleared payment required by Section 2, Claimant releases the Settling Party and the Released Persons named in Section 1.4 from Claimant’s claims for personal injury arising from the Incident, whether known or unknown on the signing date, except the claims reserved in Section 1.5 and the duties created by this Agreement.

3.2 This release is Claimant’s own release. It does not purport to release a lienholder, government program, insurer, or other person’s independent rights.

3.3 The Settling Party releases Claimant from the following claims arising from the Incident, if any: [DESCRIBE OR WRITE “NONE”]. This release also takes effect only after full cleared payment.

4. Liens and reimbursement interests

4.1 The parties disclose in Schedule A each known medical-provider lien, health-plan reimbursement demand, government recovery claim, or other claim to these proceeds. Each party shall provide the other with copies of notices it has received concerning such a claim.

4.2 The parties will resolve the listed interests as allocated in Schedule A. An unlisted or later-asserted interest will be handled by [DESCRIBE REVIEW, NOTICE, RESERVE, AND PAYMENT RESPONSIBILITY]. Nothing here changes a third party’s rights.

4.3 Any disputed amount held in escrow will be held by [ESCROW HOLDER] under a separate written escrow instruction signed by the parties and the holder. The undisputed balance shall be paid by the date in Section 2.1.

5. Pending litigation

5.1 If the case in Section 1.3 is pending, Claimant shall deliver a signed stipulation of dismissal with prejudice after full cleared payment. Every party who has appeared in that case must sign the stipulation for dismissal under Indiana Trial Rule 41(A)(1)(b). The stipulation shall be filed by [RESPONSIBLE PARTY] within [____] business days after payment.

5.2 No dismissal or release of the Settling Party takes effect before the full cleared payment required by this Agreement, unless the parties sign a separate written escrow arrangement.

6. General terms

6.1 Each party pays its own legal fees and expenses unless otherwise stated here: [________________________________].

6.2 The parties make no promise about tax treatment, insurance coverage, or the amount of a third party’s recovery claim in this Agreement.

6.3 This Agreement is governed by Indiana law. A change to this Agreement must be in writing and signed by both parties.

6.4 This Agreement, including Schedule A, states the parties’ entire settlement of the Incident to the extent described in Section 1. It binds the signers and their permitted successors. If one provision cannot be enforced, the remainder will continue to the extent it can operate as agreed.

6.5 Each signer states that they have read this Agreement, had the opportunity to seek independent advice, and sign voluntarily. The Claimant signs on their own behalf and represents that no guardian or other representative approval is needed for their signature.

Signatures

Claimant

Signature: ___________________________________ Date: [__/__/____]

Printed name: [________________________________]

Settling Party

Signature: ___________________________________ Date: [__/__/____]

Printed name and title, if signing for an entity: [________________________________]

Other Released Person, if separately agreeing to a duty in this Agreement

Signature: ___________________________________ Date: [__/__/____]

Printed name: [________________________________]

Schedule A — Known recovery interests and payment allocation

If none are known, write “none”: [________________________________].

Claimant initials: [________] Settling Party initials: [________]

Source

• Indiana Trial Rule 41(A)(1)(b) governs stipulated dismissal of a pending action.