PERSONAL INJURY SETTLEMENT AGREEMENT AND MUTUAL RELEASE

(Kansas – Court-Approved Format)

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
   3.1 Settlement Payment & Consideration
   3.2 Conditions Precedent
   3.3 Lien Resolution & Medicare Compliance
   3.4 Structured Settlement (Optional)
   3.5 Minor Settlement Approval (If Applicable)
4. Representations & Warranties
5. Covenants & Restrictions
6. Default & Remedies
7. Risk Allocation
8. Dispute Resolution
9. General Provisions
10. Execution Block

1. DOCUMENT HEADER

Personal Injury Settlement Agreement and Mutual Release (this “Agreement”) made and entered into as of [EFFECTIVE DATE] (the “Effective Date”) by and between:

a. [CLAIMANT FULL LEGAL NAME], [individual | natural guardian of minor | court-appointed conservator], having an address at [ADDRESS] (“Claimant”); and

b. [DEFENDANT/RELEASED PARTY FULL LEGAL NAME], a [corporation / LLC / individual] organized under the laws of [STATE OF ORGANIZATION] with its principal place of business at [ADDRESS] (“Released Party”).

Recitals
A. On [DATE OF INCIDENT], Claimant allegedly sustained personal injuries in [CITY, KANSAS] arising out of [BRIEF DESCRIPTION OF INCIDENT] (the “Incident”).
B. Claimant has asserted, or may assert, claims (the “Action”) against Released Party for damages arising from the Incident.
C. Released Party denies all liability but wishes to compromise and settle the Action.
D. The Parties desire to fully, finally, and irrevocably settle the Action upon the terms set forth herein.

NOW, THEREFORE, in consideration of the mutual promises, covenants, and releases set forth below, and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Parties agree as follows:

2. DEFINITIONS

For ease of reference, the following terms shall have the meanings indicated below. Defined terms appear alphabetically and apply throughout this Agreement (including the Recitals).

“Action” means any and all past, present, or future civil, administrative, or other proceedings arising from the Incident.

“Agreement” has the meaning set forth in the opening paragraph.

“Applicable Law” means all federal, state, and local statutes, regulations, and common-law principles governing the Parties’ rights and obligations, including but not limited to the Kansas Structured Settlement Protection Act, Kan. Stat. Ann. § 40-4601 et seq. (2023).

“Claimant” has the meaning set forth in the Document Header.

“Conditions Precedent” has the meaning set forth in Section 3.2.

“Court” means the District Court of [COUNTY], Kansas or any other court of competent jurisdiction approving this Agreement.

“Effective Date” has the meaning set forth in the Document Header.

“Incident” has the meaning set forth in Recital A.

“Minor” means an individual who has not attained the age of eighteen (18) years under Kansas law.

“Parties” means Claimant and Released Party, collectively; “Party” means any one of them.

“Released Claims” has the meaning set forth in Section 7.1(a).

“Released Parties” has the meaning set forth in Section 7.1(b).

“Settlement Amount” means the total monetary consideration identified in Section 3.1(a).

“Structured Settlement” means the periodic payment arrangement, if any, described in Section 3.4.

3. OPERATIVE PROVISIONS

3.1 Settlement Payment & Consideration

a. Payment Obligation. Released Party shall pay Claimant the total gross amount of [US$ SETTLEMENT AMOUNT] (the “Settlement Amount”), subject to Section 3.2 and all applicable withholdings and deductions.
b. Payment Method. Unless a Structured Settlement is elected under Section 3.4, the Settlement Amount shall be paid in a single lump-sum by [wire transfer / cashier’s check] to the trust account of Claimant’s counsel within [NUMBER] business days after satisfaction of all Conditions Precedent.
c. Consideration. The Settlement Amount and the mutual promises herein constitute adequate consideration for the releases and covenants contained in this Agreement.

3.2 Conditions Precedent

Payment of the Settlement Amount is expressly contingent upon satisfaction (or written waiver by Released Party) of all the following conditions (collectively, the “Conditions Precedent”):
1. Full execution and delivery of this Agreement by all Parties;
2. Delivery to Released Party of:
i. an executed IRS Form W-9 for Claimant (or guardian/conservator, as applicable);
ii. a signed court order approving the settlement if required under Section 3.5; and
iii. any additional closing documentation reasonably requested by Released Party;
3. Claimant’s counsel provides written confirmation that all health-care, workers’ compensation, Medicare/Medicaid, ERISA, TRICARE, and other statutory or contractual liens have been identified and will be resolved in accordance with Section 3.3.

3.3 Lien Resolution & Medicare Compliance

a. Claimant shall be solely responsible for the satisfaction, compromise, or discharge of all liens, subrogation interests, and third-party reimbursement claims (“Liens”) arising from the Incident.
b. Claimant represents that the Settlement Amount is intended to comply with the Medicare Secondary Payer Act and related regulations, and that any Medicare Set-Aside arrangement, if necessary, will be fully funded from Claimant’s share of the Settlement Amount.
[// GUIDANCE: Insert jurisdiction-specific Medicare Set-Aside language if CMS approval is sought.]

3.4 Structured Settlement (Optional)

a. Election. If the Parties elect to fund all or part of the Settlement Amount through a Structured Settlement, Schedule A shall set forth (i) the periodic payment schedule, (ii) the annuity issuer, and (iii) the qualified assignment company.
b. Compliance. Any Structured Settlement shall comply with (i) Section 104(a)(2) of the Internal Revenue Code, (ii) Rev. Proc. 93-34, and (iii) the Kansas Structured Settlement Protection Act, Kan. Stat. Ann. § 40-4601 et seq. (2023).
c. Assignment. Claimant may not assign, commute, accelerate, or encumber future periodic payments except as permitted under the Kansas Structured Settlement Protection Act and upon Court approval.

3.5 Minor Settlement Approval (If Applicable)

If Claimant is a Minor, or if any portion of the Settlement Amount is payable to or for the benefit of a Minor:
a. The settlement is null and void unless and until approved by the Court pursuant to applicable Kansas probate and civil procedure rules.
b. The Parties shall cooperate in submitting a joint petition for approval, appointing a conservator or guardian ad litem if required, and placing funds into a court-approved restricted account, trust, or annuity.
[// GUIDANCE: Insert county-specific practice pointers (e.g., Johnson or Sedgwick County procedures) as needed.]

4. REPRESENTATIONS & WARRANTIES

Each Party represents and warrants to the other that:
a. Authority. It has full authority and capacity to enter into and perform this Agreement, and, if an entity, that execution has been duly authorized.
b. No Assignment of Claims. It has not sold, assigned, pledged, or otherwise transferred any claim or right released herein.
c. Independent Counsel. It has had the opportunity to consult with independent legal counsel of its choice and enters into this Agreement voluntarily and with full understanding of its legal effect.
d. No Reliance. It is not relying on any statement or representation not expressly set forth in this Agreement.

All representations and warranties shall survive the Effective Date.

5. COVENANTS & RESTRICTIONS

5.1 Confidentiality. Except to the extent (i) required by law or Court order, or (ii) necessary to enforce this Agreement or satisfy tax or insurance obligations, the Parties shall keep the terms of this Agreement strictly confidential.

5.2 Non-Disparagement. Each Party agrees to refrain from making statements, whether written or oral, that disparage or demean the other Party in connection with the Incident.

5.3 Further Assurances. Each Party shall execute and deliver such additional documents and take such further actions as may be reasonably necessary to effectuate the intent of this Agreement.

5.4 Tax Matters. Claimant acknowledges that neither Released Party nor its counsel has provided tax advice, and Claimant shall rely solely on his, her, or its own advisors.

6. DEFAULT & REMEDIES

6.1 Default by Released Party. Failure to pay the Settlement Amount in accordance with Section 3.1 shall constitute a default. Released Party shall have a ten (10) day cure period after written notice. If uncured, Claimant may:
a. obtain a judgment for the unpaid Settlement Amount plus interest at [-%] per annum;
b. recover reasonable attorneys’ fees and costs incurred in enforcement; and
c. reinstate the Action at Claimant’s sole discretion.

6.2 Default by Claimant. Breach of the confidentiality or non-disparagement covenants shall entitle Released Party to injunctive relief and liquidated damages of [US$ AMOUNT] per breach, which the Parties agree is a reasonable estimate of probable damages and not a penalty.

7. RISK ALLOCATION

7.1 Mutual Release

a. Released Claims. Effective upon payment of the Settlement Amount, each Party hereby releases and forever discharges the other Party and all Released Parties from any and all claims, demands, causes of action, damages, costs, expenses, and liabilities of every kind, whether known or unknown, suspected or unsuspected, arising out of or relating to the Incident (collectively, the “Released Claims”).
b. Released Parties. “Released Parties” include (i) each Party’s past, present, and future parents, subsidiaries, affiliates, shareholders, officers, directors, employees, agents, insurers, reinsurers, attorneys, successors, and assigns, and (ii) any other person or entity that could be liable for the Released Claims.

7.2 Limitation of Liability

Notwithstanding any contrary provision, the Settlement Amount shall constitute the maximum aggregate liability of Released Party with respect to the Incident.

7.3 No Admission of Liability

This Agreement is a compromise of disputed claims and shall not be construed as an admission of liability or wrongdoing by either Party.

7.4 Force Majeure

No Party shall be liable for delayed performance caused by events beyond its reasonable control, including natural disasters, war, terrorism, or governmental action, provided that the affected Party promptly notifies the other Party and resumes performance as soon as practicable.

8. DISPUTE RESOLUTION

8.1 Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the State of Kansas, without regard to its conflicts-of-law rules.

8.2 Forum Selection. Any action arising out of or relating to this Agreement shall be brought exclusively in the District Court of [COUNTY], Kansas, and each Party irrevocably submits to the personal jurisdiction of such court.

8.3 Arbitration & Jury Trial. The Parties expressly waive any contractual right to arbitration. Nothing herein constitutes a waiver of any constitutional right to a jury trial, and any such waiver must be separately executed.

9. GENERAL PROVISIONS

9.1 Amendment & Waiver. No amendment or waiver of any provision shall be effective unless in writing and signed by all Parties.

9.2 Assignment. No Party may assign, delegate, or otherwise transfer its rights or obligations under this Agreement without the prior written consent of the other Party, except that Released Party may assign its payment obligations to a qualified assignment company under Section 3.4.

9.3 Severability. If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force and effect, and the invalid provision shall be reformed to the minimum extent necessary to make it valid.

9.4 Integration. This Agreement constitutes the entire agreement of the Parties with respect to its subject matter and supersedes all prior oral or written agreements.

9.5 Counterparts; Electronic Signatures. This Agreement may be executed in one or more counterparts (including by facsimile or electronic PDF), each of which shall be deemed an original but all of which together shall constitute one instrument.

10. EXECUTION BLOCK

IN WITNESS WHEREOF, the Parties have executed this Agreement as of the Effective Date.

[// GUIDANCE: Attach notary blocks below if local practice or court rule requires notarization.]

ATTORNEY ACKNOWLEDGMENT

The undersigned, counsel for Claimant, hereby certifies that he/she has explained the terms and legal effect of this Agreement to Claimant (and to Claimant’s parent/guardian/conservator, if applicable) and believes that Claimant understands and voluntarily accepts the same.

Signature: ____
Name: [ATTORNEY NAME]
Kansas Bar Number: [NUMBER]
Date: ______

End of Document