Personal Injury Settlement Agreement - Massachusetts

PERSONAL INJURY SETTLEMENT AGREEMENT AND RELEASE

(Massachusetts)

1. Parties and Dispute

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 funding person, if a party: [NAME, CAPACITY, AND ADDRESS]

The disputed claim arises from an incident on [__/__/____] at [LOCATION]
(the “Incident”). Claimant asserts injury and damages; Defendant denies
liability. The Parties intend to resolve only the claims and parties expressly
identified in this Agreement.

2. Defined Scope

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

“Released Claims” means only the claims listed in Exhibit A through the stated
Release Date. It excludes every 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 a complete reviewed list.

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

3. Funding

Total consideration: $[AMOUNT].

Select and complete:

• ☐ Lump sum due [NUMBER] calendar days after all funding conditions occur
• ☐ Periodic payments described completely in Exhibit B
• ☐ Other consideration: [DESCRIPTION]

Exhibit C must state every payee, amount or reserve, payment method, deadline,
escrow condition, lien or reimbursement holdback, attorney fee and cost, and
restricted, trust, or custodial account.

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

4. Conditions and Effective Date

Select every applicable condition:

• ☐ Signature by all Parties and authorized representatives
• ☐ Completion of the workers' compensation review in Section 5
• ☐ Entry of an approval order identified in Exhibit D
• ☐ Delivery of dismissal papers to escrow
• ☐ Final lien or reimbursement figures, releases, or agreed holdbacks
• ☐ Delivery of periodic-payment funding documents
• ☐ Other: [DESCRIPTION]

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

If a condition fails, the treatment of signatures, escrowed papers, funds,
deadlines, and pending claims is: [TERMS].

5. Massachusetts Workers' Compensation Gate

Complete before execution:

• ☐ No workers' compensation was paid or is payable for the Incident after
  counsel's review.

• ☐ Workers' compensation was paid or may be payable. Exhibit D identifies the
  employee, employer, insurer, benefits, third-party action, reimbursement and
  future-credit issues, family allocations, hearing, and approval route under
  Mass. Gen. Laws ch. 152, § 15.

Section 15 can require approval by the Department of Industrial Accidents
board or reviewing board, or by the court where the action is pending, and an
opportunity for both employee and insurer to be heard. This form does not
assume that a private signature alone completes that process.

6. Capacity and Other Approval Gate

Select one:

• ☐ Adult Claimant signs personally with legal capacity.

• ☐ Claimant acts through a fiduciary, guardian, conservator, estate
  representative, or other representative. Exhibit D attaches the appointment
  and identifies every authority limit and required approval.

• ☐ A minor, incapacity, wrongful-death, probate, structured-payment, or other
  approval issue exists. Exhibit D identifies the current governing authority,
  petition, notice, hearing, findings, account or trust, bond, and order.

No signer represents that a particular approval route applies unless Exhibit D
states the current authority and supporting facts.

7. Recovery Interests

Exhibit C must separately inventory every asserted hospital, provider,
Medicare, Medicaid or MassHealth, insurer, benefit-plan, workers'
compensation, child-support, attorney, litigation-funding, assignment,
subrogation, reimbursement, or other payment interest.

No blanket indemnity is created. Any indemnity must identify the indemnifying
person, protected person, specific third-party claim, notice, defense control,
settlement consent, exclusions, and liability measure in Exhibit C.

8. Release and Reserved Claims

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

Select the intended scope:

• ☐ Only known claims listed in Exhibit A are released.

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

• ☐ Reserved claims, parties, benefits, liens, enforcement rights, later
  conduct, or time periods: [TERMS].

Defendant's reciprocal release, if any: [NONE / PRECISE TERMS].

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

9. Dismissal and Enforcement

• ☐ 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 met.

• ☐ Other sequence: [TERMS].

Cure period: ☐ none ☐ [NUMBER] calendar days after written notice, except
[EXCEPTIONS].

Enforcement remedies and any fee or interest term must be stated here with
supporting authority: [TERMS]. No automatic fee shifting, specific
performance, interest, force majeure, or settlement-amount liability cap is
created by this form.

10. Governing Law and General Terms

Massachusetts substantive law governs, subject to a valid choice-of-law
analysis recorded here: [TERMS]. Any filing must be made in a court with
subject-matter jurisdiction and proper venue.

No jury waiver or arbitration requirement is included. Any proposed waiver or
arbitration clause requires a separate, conspicuous, claim-specific rider.

This Agreement and its completed exhibits contain the entire settlement. An
amendment must be in a signed writing and must receive any approval required
for the original Agreement. Invalid terms are severed only to the extent a
court may lawfully do so without changing the negotiated exchange.

11. Signatures

Additional representative, insurer, or funding-party signatures:
[________________________________].

Exhibit A — Released Parties, Claims, and Reservations

[COMPLETE SCHEDULE]

Exhibit B — Periodic Payments, if Any

[COMPLETE SCHEDULE]

Exhibit C — Funding, Fees, Costs, and Recovery Interests

[COMPLETE SCHEDULE]

Exhibit D — Authority and Approval Materials

[COMPLETE SCHEDULE]

Official Source

• Mass. Gen. Laws ch. 152, § 15