Personal Injury Settlement Agreement - Kentucky

PERSONAL INJURY SETTLEMENT AGREEMENT AND RELEASE

(Kentucky)

1. PARTIES, INCIDENT, AND PURPOSE

This Personal Injury Settlement Agreement and Release (the “Agreement”) is
entered into by:

• Claimant / Releasor: [FULL LEGAL NAME AND ADDRESS]
• Defendant / Releasee: [FULL LEGAL NAME, ENTITY TYPE, AND ADDRESS]
• Insurer or other funding person, if a party: [NAME, CAPACITY, ADDRESS]

The disputed claim arises from an incident on [__/__/____] at
[LOCATION] (the “Incident”). Claimant asserts injury and damages; Defendant
denies liability. The Parties wish to resolve only the claims and parties
identified in this Agreement, subject to the completed funding, approval,
recovery-interest, and dismissal exhibits.

2. DEFINED SETTLEMENT SCOPE

“Approval Order” means each court, administrative, fiduciary, or other approval
that Kentucky counsel identifies in Exhibit D.

“Effective Date” means the last completed event selected in Section 4.

“Released Claims” means only the claims described in Exhibit A through the
stated Release Date. It excludes each reserved claim, later event, and
enforcement right listed there.

“Released Parties” means only the persons and entities individually named in
Exhibit A. A category label does not replace deliberate identification.

“Settlement Amount” means the total consideration stated in Section 3.

3. SETTLEMENT FUNDING

3.1 Total consideration: $[AMOUNT].

3.2 Funding method:

☐ Lump sum of $[AMOUNT] due [NUMBER] calendar days after all funding conditions
occur.

☐ Periodic payments described completely in Exhibit B.

☐ Other consideration: [DESCRIPTION].

3.3 Exhibit C states every payee, amount or reserve, method, deadline, escrow
condition, recovery-interest holdback, attorney fee and cost, and any court-
restricted or fiduciary account.

3.4 No receipt is acknowledged until the promised funds or funding instruments
are actually delivered.

3.5 No Party relies on this form for tax characterization, reporting, public-
benefit eligibility, special-needs planning, annuity security, qualified-
assignment treatment, or professional-responsibility advice. Any negotiated
position must appear in Exhibit C after advisor review.

4. CONDITIONS AND EFFECTIVE DATE

Select every applicable condition:

☐ Signature by all Parties and required representatives

☐ Entry of each Approval Order identified in Exhibit D

☐ Delivery of dismissal papers to escrow

☐ Final Medicaid amount, agreement, allocation procedure, or holdback

☐ Final Medicare, attorney-lien, workers' compensation, insurer, benefit-plan,
medical-provider, child-support, or other recovery-interest procedure

☐ Delivery of periodic-payment funding documents

☐ Other: [DESCRIPTION]

The Effective Date occurs upon: [IDENTIFY THE LAST REQUIRED EVENT].

If required approval is denied, state what happens to signatures, escrowed
documents, funds, deadlines, and pending claims: [TERMS].

5. CAPACITY AND APPROVAL GATE

If Claimant is a minor, lacks capacity, acts through a guardian or conservator,
represents an estate, or otherwise may require approval, Exhibit D must identify:

• the correct proceeding, court, and venue;
• every representative's appointment and authority;

• any guardian ad litem, independent review, petition, notice, hearing, finding,
  bond, trust, restricted-account, or distribution requirement; and

• the order that must be entered before the release, funding, or dismissal
  becomes effective.

KRS 387.280 is not a general minor-settlement statute. It applies to its narrow
facts: a person under disability who has reached age 18, has no guardian or
conservator, and is to receive no more than $10,000 exclusive of interest. If
that section applies, the settlement or compromise requires the court approval
and payment order described there.

Do not infer a general dollar threshold, next-friend power, guardian role,
restricted-account term, or notarial requirement from this form.

6. DISMISSAL AND FUNDING SEQUENCE

☐ No action is pending.

☐ A claimant-signed dismissal is delivered to [ESCROW / COUNSEL] and may be
filed only after written confirmation that all funding conditions are satisfied.

☐ Funding is delivered to escrow and released only after [EVENT].

☐ Other sequence: [TERMS].

Any dismissal is with prejudice only as to the Released Claims against the
Released Parties unless Exhibit A expressly and validly states otherwise.
Litigation fees and costs are allocated as follows: [TERMS].

7. RECOVERY INTERESTS, LIENS, AND HOLDBACKS

7.1 Kentucky Medicaid

KRS 205.624 assigns to the Cabinet for Health and Family Services a recipient's
third-party-payment rights to the extent of medical assistance paid and gives
the Cabinet a recovery right up to the covered medical-assistance expenditures.
The claimant must notify the Cabinet when the action or proceeding begins and
of any settlement or judgment.

If KRS 205.624 applies, Exhibit C shall record:

• the recipient and identifying claim information;
• the Cabinet and any managed-care contact;
• notice dates for the action, settlement, and judgment;
• payment history, claimed amount, dispute or allocation status;
• agreed payment or holdback; and
• the person responsible for final notice, payment, and written confirmation.

7.2 Attorney lien

KRS 376.460 creates an attorney lien on covered claims placed with the attorney
for suit or collection or on which suit was instituted, and on a money or
property judgment recovered, subject to the statute's terms. Exhibit C shall
identify each current or former attorney, fee agreement, notice, asserted lien,
dispute, holdback, consent, and payment.

7.3 Other asserted interests

Exhibit C must separately inventory and assign responsibility for every asserted
Medicare, Medicaid managed-care, insurer, ERISA or other benefit-plan, workers'
compensation, medical-provider, attorney, litigation-funding, child-support,
assignment, subrogation, reimbursement, or other payment interest.

No blanket statement that no liens exist and no general claimant indemnity
substitutes for the completed inventory. Any claim-specific indemnity must name
the indemnifying person, protected person, claim, notice, defense control,
settlement authority, exclusions, duration, and liability measure.

8. RELEASE AND RESERVED CLAIMS

8.1 On the Effective Date and subject to actual funding, Claimant releases the
Released Parties from the Released Claims identified in Exhibit A.

8.2 Known and unknown claims. Select and describe the intended result:

☐ Only known claims listed in Exhibit A are released.

☐ Defined unknown consequences of the Incident are included after counsel
review: [TERMS].

☐ The following claims, parties, benefits, liens, enforcement rights, later
conduct, or time periods are reserved: [TERMS].

8.3 Defendant release:

☐ No reciprocal release.

☐ Defendant releases Claimant from only these claims: [TERMS].

8.4 Exhibit A states whether claims against every nonsettling person are
reserved and how settlement credit, contribution, indemnity, or allocation
issues are handled after Kentucky counsel review.

8.5 This Agreement compromises disputed claims and is not an admission of
liability.

9. OPTIONAL CONDUCT TERMS

9.1 Confidentiality

☐ None.

☐ Limited to: [INFORMATION / PERSONS / DURATION].

Permitted disclosures must cover legal process, approval proceedings, tax and
benefit reporting, recovery-interest resolution, insurance administration,
medical care, regulators and government, and confidential professional advice.

9.2 Non-disparagement

☐ None.

☐ Narrow restriction: [TERMS].

The clause does not prohibit truthful testimony, legal process, protected
government communications, medical care, insurance or benefit administration,
or confidential advice.

9.3 Cooperation

Further documents may implement the completed exhibits but may not expand the
Released Claims, Released Parties, or payment duties without a signed amendment
and any required approval.

10. DEFAULT AND REMEDIES

10.1 A material failure to perform an express obligation after its conditions
occur is a default. A disputed recovery interest, approval condition, or escrow
instruction is not automatically a default unless this Agreement allocates that
risk.

10.2 Cure:

☐ No contractual cure period.

☐ Written notice and [NUMBER] calendar days to cure, except [EXCEPTIONS].

10.3 Select negotiated remedies after counsel review:

☐ Action to enforce the Agreement

☐ Judgment for an unpaid liquidated amount

☐ Contract interest at [RATE] beginning [DATE], supported by [CONTRACT / LAW]

☐ Agreed dismissal or restoration procedure: [TERMS]

☐ Other: [TERMS]

10.4 Fees:

☐ Each Party bears its own enforcement fees and costs except as a court
otherwise awards under governing law.

☐ Claim-specific fee provision: [TERMS AND AUTHORITY].

No automatic interest, specific performance, fee shifting, reimbursement of the
Settlement Amount, or fixed cure period is created by this form.

11. RISK ALLOCATION

The Settlement Amount is consideration for the Released Claims, not a cap on
liability for breach of this Agreement. No force-majeure term excuses funding,
approval, escrow, recovery-interest, dismissal, or confidentiality duties unless
the Parties insert a specific counsel-reviewed clause here: [TERMS].

There is no general mutual or claimant indemnity. Any claim-specific allocation
must appear in Exhibit C and may not waive a nonwaivable duty or bind a person
without authority and assent.

12. PERIODIC PAYMENTS AND LATER TRANSFERS

If periodic payments are selected, Exhibit B must identify each payment, payee,
date, funding asset, obligor, assignee, annuity issuer, beneficiary, death-
payment term, cost disclosure, and tax or qualified-assignment assumption
supplied by the Parties' advisors.

KRS 454.431 governs a later transfer of structured-settlement payment rights; it
does not itself require court approval of the initial periodic-payment funding.
No later transfer is effective without the advance court order and express
findings required by that section. This Agreement does not authorize a future
sale, assignment, pledge, or other transfer of payment rights.

13. GOVERNING LAW AND DISPUTES

Kentucky substantive law governs this Agreement, subject to any valid choice-
of-law analysis counsel records here: [TERMS].

Any filing must be made in a court with subject-matter jurisdiction and proper
venue. Proposed forum: [COURT / COUNTY], subject to governing law and every
Approval Order.

Select one:

☐ Court proceedings; no contractual arbitration requirement

☐ Mediation before a non-emergency enforcement filing

☐ Arbitration under the attached counsel-completed rider

No jury waiver is included. Any proposed waiver requires a separate,
conspicuous, claim-specific provision reviewed under current Kentucky law.

14. GENERAL TERMS

Entire agreement. This Agreement and completed exhibits contain the
settlement terms.

Amendments. An amendment or waiver must be in a record signed by every
affected Party and approved through any required process.

Assignment. No assignment or delegation is permitted except as expressly
stated in Exhibit B or D or later approved in a signed writing.

Severability. A provision may be severed only if permitted by governing law
and doing so does not materially alter the settlement exchange or release scope.

Persons bound. Only a signatory and persons or entities that signatory has
authority to bind are bound. Exhibit A must identify every intended beneficiary
or bound representative, estate, insurer, successor, or assignee.

Counterparts and electronic process. The Parties select:

☐ Wet-ink originals required for: [DOCUMENTS].

☐ The Parties agree to conduct this transaction electronically. KRS 369.105
makes party agreement the gate; KRS 369.107 prevents denial of legal effect
solely because a record or signature is electronic, subject to other applicable
law and any Approval Order.

Notarial act. Use a current Kentucky notarial certificate only if counsel,
an Approval Order, escrow, or another applicable requirement calls for one.

Notices. Required notices are sent by [METHOD] to [ADDRESSES] and become
effective upon [DELIVERY EVENT].

15. SIGNATURES

CLAIMANT / RELEASOR

Signature: ______________________________________

Name: [NAME]

Date: [__/__/____]

Representative capacity and authority document, if any: [DETAILS]

DEFENDANT / RELEASEE

Signature: ______________________________________

Name and title: [NAME / TITLE]

Date: [__/__/____]

OTHER REQUIRED PARTY

Signature: ______________________________________

Name, capacity, and authority: [DETAILS]

Date: [__/__/____]

16. EXHIBITS

• Exhibit A — Released Parties, Released Claims, Reserved Claims, and Other
  Alleged Tortfeasors

• Exhibit B — Funding, Periodic Payments, Assignment, Annuity, and Beneficiary
  Terms

• Exhibit C — Payment Allocation, Fees, Costs, Recovery Interests, Holdbacks,
  and Any Claim-Specific Indemnity

• Exhibit D — Capacity, Fiduciary Authority, Approval, Restricted Funds, and
  Distribution Terms

• Exhibit E — Dismissal and Escrow Documents

SOURCES AND REFERENCES

• KRS 205.624: https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=7751
• KRS 376.460: https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=35338
• KRS 387.280: https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=52167
• KRS 454.431: https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=19615
• KRS 369.105: https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=35204
• KRS 369.107: https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=35206