PERSONAL INJURY SETTLEMENT AGREEMENT
AND MUTUAL RELEASE
(Indiana)
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
This Personal Injury Settlement Agreement and Mutual Release (the “Agreement”) is entered into as of [EFFECTIVE DATE] (the “Effective Date”) by and among:
• [CLAIMANT FULL LEGAL NAME], individually [and, if applicable, as Parent/Guardian of Minor, [MINOR NAME]] (“Claimant” or “Releasor”);
• [DEFENDANT FULL LEGAL NAME], together with its parents, subsidiaries, affiliates, employees, officers, directors, insurers, reinsurers, and assigns (“Released Party”); and
• [INSURER/THIRD-PARTY ADMINISTRATOR] (if applicable).
Recitals:
A. On or about [DATE OF INCIDENT], Claimant allegedly sustained personal injuries (the “Incident”).
B. Claimant has asserted or may assert tort claims against Released Party arising from the Incident (the “Claims”).
C. The Parties desire to fully and finally resolve the Claims without admission of liability.
D. For good and valuable consideration, the receipt and sufficiency of which are acknowledged, the Parties agree as follows.
[// GUIDANCE: Modify Recitals to match factual background precisely.]
2. DEFINITIONS
For purposes of this Agreement, capitalized terms shall have the meanings set forth below. Terms defined in the singular include the plural and vice-versa.
“Agreement” – This Personal Injury Settlement Agreement and Mutual Release, including all Exhibits and Schedules.
“Claim(s)” – Any and all past, present, or future claims, causes of action, liabilities, demands, damages, costs, expenses, liens, and rights of whatever kind arising out of or relating to the Incident.
“Court Approval” – A valid order issued by a court of competent jurisdiction in Indiana approving settlement of a minor’s claim pursuant to Ind. Code § 29-3-3-1 et seq.
“Effective Date” – The date first written above or, if later, the date on which all Parties have executed this Agreement.
“Healthcare Liens” – All Medicare, Medicaid, ERISA, hospital, medical provider, or other statutory or contractual liens relating to the Incident.
“Payment Schedule” – The consideration payable under Section 3.1.
“Released Parties” – Released Party and all persons and entities identified in Section 7.1(a).
“Structured Settlement” – Any periodic payment arrangement complying with the Indiana Structured Settlement Protection Act, Ind. Code § 34-50-2 et seq., and Internal Revenue Code §§ 104(a)(2), 130.
3. OPERATIVE PROVISIONS
3.1 Consideration
(a) Lump-Sum Option.
The Released Party shall pay Claimant a total sum of $[SETTLEMENT AMOUNT] (“Settlement Proceeds”) within [__] business days after (i) receipt of a fully executed Agreement, (ii) delivery of a duly executed Stipulation of Dismissal with prejudice in the form attached as Exhibit A, and (iii) compliance with Section 3.4 (Liens).
(b) Structured Settlement Option.
In lieu of or in addition to the lump-sum payment, the Parties may agree to a Structured Settlement as set forth in Schedule 1 (Structured Payment Terms). All structured payments shall be funded through an assignment to a qualified assignee and purchase of an annuity contract from [ANNUITY ISSUER] in accordance with Ind. Code § 34-50-2 and I.R.C. §§ 104(a)(2), 130.
[// GUIDANCE: Delete the option not selected and attach Schedule 1 if a structure is used.]
3.2 Conditions Precedent
The obligations of Released Party are expressly conditioned upon:
1. Execution and delivery of this Agreement by all Parties;
2. Receipt of Court Approval if Claimant is a minor or otherwise subject to guardianship; and
3. Receipt of all documents reasonably necessary to verify satisfaction of Healthcare Liens.
3.3 Dismissal of Litigation
Within three (3) business days after receipt of the Settlement Proceeds, Claimant shall file the Stipulation of Dismissal with prejudice in the [NAME OF COURT], Cause No. [CASE NUMBER], with each Party to bear its own costs.
3.4 Healthcare Liens & Government Reporting
(a) Claimant represents that all Healthcare Liens are accurately disclosed on Schedule 2. Claimant shall be solely responsible for satisfaction of, and shall indemnify Released Parties against, any unsatisfied liens.
(b) The Parties shall comply with the Medicare Secondary Payer Act, 42 U.S.C. § 1395y(b), including timely reporting to the Centers for Medicare & Medicaid Services (CMS), if applicable.
4. REPRESENTATIONS & WARRANTIES
4.1 Mutual Representations. Each Party represents and warrants that:
a. It has full right, power, and authority to enter into and perform this Agreement.
b. The execution and performance of this Agreement do not violate any other agreement or court order.
4.2 Claimant Specific. Claimant further represents and warrants that:
a. Claimant is the sole owner of the Claims and has not assigned or transferred any interest therein;
b. Claimant has consulted (or knowingly declined to consult) independent legal counsel regarding this Agreement;
c. If Claimant is a minor, the individual executing on Claimant’s behalf is duly appointed and authorized as parent, guardian, or next friend and will seek Court Approval forthwith.
4.3 Survival. All representations and warranties shall survive the Effective Date and consummation of the settlement.
5. COVENANTS & RESTRICTIONS
5.1 No Further Claims. Claimant covenants not to commence or prosecute any action or proceeding based upon any Released Claim.
5.2 Confidentiality. Except as required by law, court order, or insurer reporting obligations, the Parties shall keep the terms of this Agreement confidential.
5.3 Non-Disparagement. The Parties agree not to make statements intended to disparage one another regarding the Incident or the settlement.
6. DEFAULT & REMEDIES
6.1 Event of Default. Failure by a Party to perform any material obligation under this Agreement within the time specified constitutes an Event of Default.
6.2 Notice & Cure. The non-defaulting Party shall provide written notice specifying the default and a cure period of ten (10) business days.
6.3 Remedies.
a. Monetary damages for breach of payment obligations shall not exceed the Settlement Proceeds plus statutory interest.
b. The Parties retain all rights at law or in equity to enforce this Agreement, provided that under no circumstances shall any Party seek rescission of the releases granted herein other than for fraud or mutual mistake recognized under Indiana law.
7. RISK ALLOCATION
7.1 Mutual Release & Indemnification
(a) Release by Claimant. Upon receipt of the Settlement Proceeds, Claimant irrevocably releases and forever discharges Released Parties from all Claims, whether known or unknown, accrued or contingent, arising out of the Incident, except for obligations expressly created by this Agreement.
(b) Release by Released Party. Upon Effective Date, Released Party releases Claimant from any claims for contribution or indemnity related to the Incident.
(c) Indemnification. Each Party shall indemnify, defend, and hold the other harmless from any third-party claim arising from its breach of representations, warranties, or covenants herein, including unpaid Healthcare Liens.
7.2 Limitation of Liability
Except for indemnification obligations under Section 7.1(c), in no event shall any Party be liable for punitive, exemplary, or consequential damages relating to this Agreement.
7.3 Force Majeure
No Party shall be liable for failure to perform due to events beyond its reasonable control, including acts of God, war, or governmental action, provided written notice is given within five (5) days of the event.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Agreement shall be governed by and construed in accordance with the tort and contract laws of the State of Indiana without regard to its conflict-of-law rules.
8.2 Forum Selection. Any action arising out of or relating to this Agreement shall be brought exclusively in the state courts of [COUNTY], Indiana, and each Party irrevocably submits to such jurisdiction.
8.3 Arbitration & Jury Waiver. The Parties expressly waive arbitration; jury trial waiver is not applicable per the Parties’ election.
9. GENERAL PROVISIONS
9.1 Entire Agreement. This Agreement constitutes the entire understanding of the Parties and supersedes all prior negotiations.
9.2 Amendment; Waiver. No amendment or waiver is effective unless in writing and signed by all Parties.
9.3 Assignment. No Party may assign its rights or delegate its duties without prior written consent of the other Parties.
9.4 Severability. If any provision is held invalid, the remainder shall be enforced to the maximum extent permitted, and the invalid provision shall be reformed to achieve its intent.
9.5 Successors & Assigns. This Agreement is binding upon and inures to the benefit of the Parties and their respective successors and permitted assigns.
9.6 Counterparts; Electronic Signatures. This Agreement may be executed in counterparts, each of which is deemed an original, and signatures transmitted electronically or by facsimile shall be deemed valid and binding.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the Parties have executed this Agreement as of the Effective Date.
CLAIMANT / RELEASOR
[NAME]
If Minor:
[NAME], Parent/Guardian of [MINOR NAME]
[// GUIDANCE: Attach Court order approving settlement for minor before funding.]
RELEASED PARTY
[AUTHORIZED SIGNATORY NAME & TITLE]
[ORGANIZATION]
INSURER / TPA (if applicable)
[AUTHORIZED SIGNATORY NAME & TITLE]
[INSURER/TPA NAME]
State of Indiana )
County of ____ ) SS:
Subscribed and sworn before me this ___ day of ____, 20__.
Notary Public
My Commission Expires: ____