Personal Injury Settlement Agreement - Maine

PERSONAL INJURY SETTLEMENT AGREEMENT AND RELEASE

State of Maine

Use note: This form is for a living, competent adult settling that adult's own identified personal-injury claim. Do not use it by merely changing the name for a minor, protected person, estate, wrongful-death claim, workers' compensation claim, class claim, governmental claim, or matter requiring court approval. Those matters require separate authority, approval, allocation, and signature analysis.

1. PARTIES, CLAIM, AND CASE

Claimant: [CLAIMANT FULL LEGAL NAME], of [ADDRESS]

Payor: [INSURER, SELF-INSURED ENTITY, DEFENDANT, OR OTHER PAYOR]

Released Party or Parties:

1. [FULL LEGAL NAME]
2. [FULL LEGAL NAME]
3. [FULL LEGAL NAME]

Incident: The occurrence on [DATE] at [LOCATION], described as [BRIEF DESCRIPTION].

Pending case, if any: [COURT], [DOCKET NUMBER], [CASE CAPTION], or None.

Settlement Amount: $[GROSS SETTLEMENT AMOUNT]

Agreement Date: [DATE]

The Released Parties deny liability. The parties compromise disputed claims without an admission of fault, wrongdoing, causation, or damages.

2. SETTLEMENT FUNDING

2.1 Payment

The Payor shall deliver the Settlement Amount by [TRUST CHECK / WIRE / OTHER REVIEWED METHOD] to [RECIPIENT OR LAW-FIRM TRUST ACCOUNT] no later than [DATE OR NUMBER OF DAYS] after all selected funding conditions in Section 2.2 are satisfied.

2.2 Funding Conditions

Select and complete every condition that applies:

☐ This Agreement has been signed by the Claimant, Payor, and each Released Party whose signature is required.

☐ The Payor has received accurate payment and tax-reporting instructions.

☐ The MaineCare notice, claim-protection, lien, release, payment, or holdback steps in Section 5 are complete.

☐ The Medicare recovery and holdback steps in Section 5 are complete.

☐ Any pending action's dismissal instrument has been signed and placed in escrow for filing after cleared funding.

☐ Other transaction-specific condition: [DESCRIBE].

2.3 Cleared Funds and Release Effective Time

Unless the parties state a different reviewed sequence here—[INSERT DIFFERENT SEQUENCE OR “NONE”]—the release in Section 4 becomes effective only when the full Settlement Amount has been received as cleared funds by the designated recipient or escrow holder. Signing alone does not acknowledge receipt of funds that have not cleared.

2.4 No Unwritten Periodic-Payment Promise

This Agreement provides a lump-sum settlement unless a separately reviewed exhibit states every periodic payment, funding asset, obligor, beneficiary, and assignment term. Do not describe a payment as a structured settlement without the complete transaction documents.

3. CLAIMANT REPRESENTATIONS

The Claimant represents, as of signing, that:

1. The Claimant is an adult with capacity to sign this Agreement.
2. The Claimant owns the claims being released and has not assigned them, except as disclosed in Schedule 1.
3. The Claimant has identified in Schedule 2 all known Medicare, MaineCare, insurer, benefit-plan, provider, attorney, and other recovery interests connected to the Incident or settlement.
4. The Claimant has had the opportunity to obtain independent legal, tax, benefits, and financial advice.
5. No promise outside this Agreement induced the settlement.

If any representation is inaccurate, stop and revise the schedules and operative terms before funding; do not rely on a generic indemnity to conceal an unresolved ownership or recovery-interest issue.

4. RELEASE

4.1 Claims Released

At the effective time in Section 2.3, the Claimant releases only the specifically named Released Parties from claims that:

1. belong to the Claimant;
2. arise out of the Incident; and
3. accrued on or before the Agreement Date.

The release includes known and unknown consequences of the Claimant's injuries from the Incident only if counsel confirms that scope and the Claimant initials here: [INITIALS].

4.2 Claims Not Released

This Agreement does not release:

1. obligations created by this Agreement;
2. claims expressly reserved in Schedule 3;
3. claims belonging to a spouse, child, estate, governmental entity, insurer, benefit plan, medical provider, or any other person or entity that has not signed a legally effective release of its own rights;
4. claims against a person or entity not named as a Released Party; or
5. rights that applicable law does not permit the Claimant to release.

4.3 Optional Reciprocal Release

No Released Party releases any claim unless this box is selected and the released claim is described precisely:

☐ [NAMED RELEASED PARTY] releases [NAMED CLAIMANT] from [SPECIFIC CLAIM] arising from the Incident.

4.4 No Admission

The payment and release are a compromise of disputed claims and are not an admission of liability or damages.

5. MEDICARE, MAINECARE, AND OTHER RECOVERY INTERESTS

5.1 Recovery-Interest Schedule

The parties shall complete Schedule 2 from actual information. Listing an interest does not concede its amount, validity, priority, or allocation.

5.2 MaineCare

If MaineCare paid benefits connected to the Incident, confirm and document the pre-negotiation notice required by 22 M.R.S. § 14(2-D), or a MaineCare claim-protection letter accepted by the Department. Before any net disbursement to the Claimant, obtain the Department's release or pay the amount required. If the Department's amount remains disputed, withhold from the Claimant an amount equal to the Commissioner's claim until it is resolved under § 14(2-F).

5.3 Medicare

If Medicare made a payment for an item or service for which a primary plan has settlement responsibility, obtain current recovery information and reimburse the appropriate Medicare Trust Fund as required by 42 U.S.C. § 1395y(b)(2)(B)(ii). State the agreed holdback, if any, in Schedule 2 rather than promising that an unknown amount is already satisfied.

5.4 Other Interests

For every private insurer, ERISA plan, provider, attorney, or other asserted interest, Schedule 2 must identify the claimant, basis, asserted amount, disputed amount, person responsible for resolution, and any holdback. This Agreement does not determine a nonparty's rights.

5.5 Disbursement Statement

Before paying the Claimant's net proceeds, the disbursing lawyer or escrow holder shall prepare a transaction-specific statement showing the gross settlement, fees and costs authorized by the Claimant's separate agreement, payments, holdbacks, and net disbursement.

6. DISMISSAL OF PENDING ACTION

If no action is pending, write “Not applicable.”

If an action is pending, the parties shall use the dismissal route applicable to the case. Under M.R. Civ. P. 41(a)(1), a plaintiff may file a notice before service of an answer or summary-judgment motion, or the appearing parties may file a signed stipulation. A dismissal is without prejudice unless the filing states otherwise.

Selected filing: [NOTICE / STIPULATION / MOTION AND ORDER / OTHER]

Selected disposition: [WITH PREJUDICE / WITHOUT PREJUDICE / PARTIAL DISMISSAL]

Filing sequence: [AFTER CLEARED FUNDS / FROM ESCROW ON WRITTEN CONFIRMATION / OTHER]

No party shall file a dismissal contrary to the selected funding sequence.

7. TAX AND BENEFITS NOTICE

The parties make no promise that every settlement dollar is excluded from income. Section 104(a)(2) of the Internal Revenue Code addresses damages, other than punitive damages, received on account of personal physical injuries or physical sickness. Interest, punitive damages, wage components, confidentiality consideration, and other allocations may be treated differently. Each party is responsible for obtaining advice and complying with its own reporting duties; any allocation must reflect the actual claims and settlement.

8. OPTIONAL CONFIDENTIALITY

Select one:

☐ No confidentiality covenant.

☐ Limited confidentiality covenant. The parties shall not voluntarily disclose [THE SETTLEMENT AMOUNT / SPECIFIED TERMS], except to counsel, tax advisers, financial advisers, immediate family who agree to maintain confidentiality, insurers, auditors, regulators, benefit programs, lien or recovery claimants, or as required by law, court order, subpoena, reporting duty, or enforcement of this Agreement.

No liquidated damages, forfeiture, repayment, non-disparagement, or speech restriction applies unless separately stated here after legal review: [TERMS OR “NONE”].

9. BREACH AND ENFORCEMENT

1. A party claiming breach shall give written notice describing the breach and requested performance unless emergency relief or a filing deadline makes notice impracticable.
2. Cure period, if agreed: [NUMBER] days. If blank, no contractual cure period is created.
3. The parties preserve the remedies otherwise available under this Agreement and applicable law. This form does not create automatic judgment, claim reinstatement, specific performance, interest, punitive damages, or attorney-fee shifting.
4. Each party bears its own fees and costs unless a court, statute, separate fee agreement, or the following negotiated term provides otherwise: [TERM OR “NONE”].

10. GENERAL TERMS

1. Governing law. Maine law governs this Agreement, subject to applicable federal law.
2. No exclusive forum or advance jury waiver. A dispute may be brought in a court with subject-matter and personal jurisdiction. No party waives a jury right in advance through this form.
3. Entire agreement. This Agreement and its completed schedules contain the parties' settlement terms.
4. Amendment. An amendment must be in writing and signed by the parties whose rights or duties it changes.
5. Severability. If a provision is unenforceable, the remainder continues to the extent the transaction can operate without the invalid provision.
6. Signature method. Counsel shall confirm the signature and delivery method appropriate to the parties, pending case, and any approval or filing requirement. This form does not deem a copy or electronic transmission an original for every purpose.
7. No drafting presumption. The parties had the opportunity to review and propose revisions; no presumption arises solely from who prepared the first draft.

11. SIGNATURES

CLAIMANT

Signature: ______________________________________

Name: [CLAIMANT NAME]

Date: __________________________________________

PAYOR

Signature: ______________________________________

Name and title: [NAME AND TITLE]

For: [PAYOR]

Date: __________________________________________

RELEASED PARTY

Signature: ______________________________________

Name and title: [NAME AND TITLE]

For: [RELEASED PARTY]

Date: __________________________________________

Add a signature block for every person or entity whose assent is required. A lawyer signs only if the lawyer is a party, escrow holder, or authorized representative and the capacity is stated.

SCHEDULE 1 — CLAIM OWNERSHIP AND ASSIGNMENTS

SCHEDULE 2 — RECOVERY INTERESTS, PAYMENTS, AND HOLDBACKS

SCHEDULE 3 — EXPRESSLY RESERVED CLAIMS

1. [RESERVED CLAIM OR “NONE”]
2. [RESERVED CLAIM OR “NONE”]

End of Maine Personal Injury Settlement Agreement and Release