PERSONAL INJURY SETTLEMENT AGREEMENT
(Missouri – Governed by State Tort Law)
[// GUIDANCE: This template is drafted to comply with Missouri law and is suitable for bodily-injury claims arising from negligence, strict liability, or intentional tort theories. Customize bracketed items, delete inapplicable provisions (e.g., “Minor Settlement” or “Structured Settlement”), and attach or reference any exhibits needed (e.g., payment schedule, court-approval order).]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1 Settlement Payment & Timing
3.2 Conditions Precedent & Subsequent - Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
7.1 Mutual Release & Covenant Not to Sue
7.2 Limitation of Liability
7.3 Medicare/Medicaid & Other Liens - Dispute Resolution
- General Provisions
- Execution Block
- Exhibits & Schedules
1. DOCUMENT HEADER
Agreement Title: Personal Injury Settlement Agreement and Mutual Release
Effective Date: [● MM/DD/YYYY] (“Effective Date”)
Parties:
(a) [Plaintiff Full Legal Name], an individual having a principal residence at [ADDRESS] (“Releasor”); and
(b) [Defendant/Insurer Full Legal Name], a [STATE OF FORMATION] [corporation/LLC/individual] with a principal place of business at [ADDRESS] (“Releasee”).
Recitals
A. A dispute has arisen out of an incident that occurred on or about [DATE OF ACCIDENT] in [CITY/COUNTY, Missouri] (the “Incident”), resulting in personal injuries and damages alleged by Releasor (collectively, the “Claims”).
B. The Parties desire to resolve all matters arising from or related to the Incident without the expense and uncertainty of litigation.
C. In consideration of the mutual covenants herein and other good and valuable consideration, the sufficiency of which is acknowledged, the Parties agree as follows.
2. DEFINITIONS
[// GUIDANCE: Defined terms are capitalized throughout. Add/delete as needed.]
“Agreement” means this Personal Injury Settlement Agreement and Mutual Release, including all Exhibits and Schedules.
“Confidential Information” has the meaning set forth in Section 5.3.
“Court” means the Circuit Court of [COUNTY], Missouri, or such other Missouri state court having jurisdiction under Mo. Rev. Stat. Chapters 479– 512.
“Gross Settlement Amount” means the total consideration payable to Releasor under Section 3.1.
“Medicare Secondary Payer Statute” means 42 U.S.C. § 1395y(b) and applicable regulations.
“Minor” means any person who has not attained eighteen (18) years of age.
“Parties” means Releasor and Releasee, and “Party” means either of them.
“Structured Settlement” has the meaning set forth in Section 3.1(b).
3. OPERATIVE PROVISIONS
3.1 Settlement Payment & Timing
(a) Lump-Sum Settlement. Releasee shall pay to Releasor (or to Releasor’s counsel in trust) the lump-sum amount of [US $__] (the “Gross Settlement Amount”) no later than [NUMBER] business days after (i) complete execution of this Agreement by all Parties and (ii) satisfaction of all Conditions Precedent in Section 3.2. Payment shall be made by [wire transfer/check] payable to “[LAW FIRM] Trust Account f/b/o [Releasor]”.
(b) Structured Settlement (if elected). In lieu of part or all of the lump-sum payment, the Parties agree to fund a structured settlement annuity (the “Structured Settlement”) with the terms set forth in Exhibit A. The Structured Settlement shall comply with:
(1) § 104(a)(2) of the Internal Revenue Code;
(2) the Missouri Structured Settlement Protection Act, Mo. Rev. Stat. §§ 407.1060–407.1068; and
(3) any applicable federal/state transfer restrictions.
[// GUIDANCE: Delete subsection (b) if no annuity is contemplated.]
3.2 Conditions Precedent & Subsequent
(a) Court Approval for Minors or Incapacitated Persons. If Releasor is a Minor or is otherwise incapacitated, this Agreement is expressly contingent upon entry of an order approving the settlement pursuant to Mo. Sup. Ct. R. 52.11 and Mo. Rev. Stat. § 507.184 (the “Approval Order”). Absent the Approval Order within [60] days of the Effective Date, either Party may terminate this Agreement upon written notice.
(b) Lien Resolution. Releasor shall provide Releasee with written confirmation that all known hospital, medical provider, workers’ compensation, subrogation, Medicare/Medicaid, and child-support liens have been satisfied or compromised to the lienholder’s written satisfaction (“Lien Releases”).
(c) Taxpayer Identification Certification. Releasor shall supply a completed IRS Form W-9 to Releasee or its insurer.
(d) Dismissal of Litigation. Within five (5) business days after receipt of payment in Section 3.1, Releasor shall file a stipulation of dismissal with prejudice in any pending litigation arising from the Incident.
4. REPRESENTATIONS & WARRANTIES
4.1 Authority. Each Party represents that it has full legal right, power, and authority to enter into and perform this Agreement; and, if a corporate entity, that all requisite corporate actions have been duly taken.
4.2 No Assignment. Releasor represents that no part of the Claims has been assigned, pledged, or otherwise transferred to any third party.
4.3 Independent Counsel. Releasor acknowledges having had the opportunity to consult with independent legal counsel of Releasor’s choice, and either has done so or voluntarily elected not to.
4.4 Medicare/Medicaid Status. Releasor represents that (check one):
☐ Releasor is not a Medicare beneficiary.
☐ Releasor is a Medicare beneficiary, and Releasor will ensure compliance with the Medicare Secondary Payer Statute regarding conditional payments and future medicals, including the establishment of a Medicare Set-Aside arrangement if required.
4.5 Truthfulness. The information provided by Releasor to Releasee concerning damages, liens, and the existence of bankruptcy proceedings is true, complete, and accurate in all material respects.
The foregoing representations and warranties shall survive the Effective Date.
5. COVENANTS & RESTRICTIONS
5.1 Non-Disparagement. Each Party covenants that it shall not make any statement, written or oral, intended or reasonably likely to disparage the other Party related to the Incident, except as required by law or court order.
5.2 Cooperation. Releasor shall execute all documents and take all actions reasonably necessary to effectuate the Releases, Lien Releases, and dismissal of litigation contemplated herein.
5.3 Confidentiality. Except as required by law, rule, regulation, or court order, the terms of this Agreement (“Confidential Information”) shall remain confidential. Permitted disclosures include:
(a) to the Parties’ attorneys, insurers, accountants, financial or tax advisors;
(b) as necessary to secure Court approval; and
(c) as otherwise mutually agreed in writing.
5.4 No Admission. Nothing herein constitutes an admission of liability; all such liability is expressly denied.
6. DEFAULT & REMEDIES
6.1 Events of Default. The following shall constitute an Event of Default:
(a) Failure of Releasee to timely fund the Gross Settlement Amount or Structured Settlement;
(b) Failure of Releasor to timely deliver executed dismissal papers, Lien Releases, or other required documentation;
(c) Material breach of Section 5 (Covenants & Restrictions).
6.2 Cure Period. The defaulting Party shall have ten (10) business days after receipt of written notice of default to cure the same.
6.3 Remedies. Upon uncured Event of Default, the non-defaulting Party may:
(a) enforce specific performance;
(b) recover reasonable attorneys’ fees and costs incurred to enforce this Agreement; and/or
(c) pursue any other remedy available at law or equity, subject to Section 7.2.
7. RISK ALLOCATION
7.1 Mutual Release & Covenant Not to Sue
(a) Release by Releasor. For and in consideration of the Gross Settlement Amount, Releasor, on behalf of [himself/herself/itself] and Releasor’s heirs, executors, administrators, agents, assigns, and successors, hereby irrevocably releases and forever discharges Releasee and Releasee’s past, present, and future parents, subsidiaries, affiliates, insurers, reinsurers, officers, directors, shareholders, employees, agents, and attorneys (“Released Parties”) from any and all past, present, or future claims, demands, actions, causes of action, suits, debts, liens, damages (actual, consequential, punitive, or otherwise), costs, expenses, and compensation of any nature whatsoever, whether known or unknown, foreseen or unforeseen, direct or indirect, arising out of or relating to the Incident (“Released Claims”).
(b) Waiver of Unknown Claims. Releasor understands and expressly waives any rights under Missouri law that might otherwise limit the scope of the Released Claims to those known or suspected at the time of execution. Releasor acknowledges the possibility of unknown injuries or damages and agrees that this Release shall apply thereto.
(c) Mutual Release by Releasee. Releasee, for itself and the Released Parties, releases Releasor from all claims arising from or relating to the Incident, excluding obligations under this Agreement.
(d) Covenant Not to Sue. Each Party covenants and agrees not to commence or maintain any legal or administrative action concerning any Released Claim, except to enforce this Agreement.
7.2 Limitation of Liability
IN NO EVENT SHALL EITHER PARTY’S MONETARY LIABILITY FOR BREACH OF THIS AGREEMENT EXCEED THE GROSS SETTLEMENT AMOUNT, EXCEPT FOR: (i) CLAIMS ARISING FROM A PARTY’S FRAUD OR WILLFUL MISCONDUCT; OR (ii) OBLIGATIONS TO REIMBURSE MEDICARE/MEDICAID OR TO INDEMNIFY FOR LIENS.
7.3 Medicare/Medicaid & Other Liens
Releasor shall indemnify, defend, and hold harmless Releasee from any claim, penalty, interest, or assessment made by any governmental agency or lienholder arising from Releasor’s failure to satisfy or report liens related to the Incident, provided that Releasee has fully funded the Gross Settlement Amount.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Agreement and any dispute arising hereunder shall be governed by and construed in accordance with the laws of the State of Missouri, without regard to conflict-of-laws principles.
8.2 Forum Selection. The Parties irrevocably submit to the exclusive jurisdiction of the Missouri state courts located in [COUNTY], and waive any objection based on forum non conveniens.
8.3 Arbitration & Jury Trial. The Parties agree that arbitration is not applicable; any action must be resolved in the designated state court. EACH PARTY WAIVES THE RIGHT TO TRIAL BY JURY ONLY IF, AND TO THE EXTENT, SUCH WAIVER IS MUTUALLY AGREED IN A SEPARATE WRITING.
8.4 Injunctive Relief. The Parties do not seek injunctive relief under this Agreement; however, the Court may enforce the confidentiality or non-disparagement provisions through equitable remedies if monetary damages are inadequate.
9. GENERAL PROVISIONS
9.1 Amendments & Waivers. No amendment or waiver shall be binding unless in a written instrument signed by both Parties. A waiver on one occasion is not a waiver on any future occasion.
9.2 Assignment & Delegation. No Party may assign its rights or delegate its obligations without the prior written consent of the other Party, except that Releasee may assign rights to an insurer or structured-settlement obligor.
9.3 Successors & Assigns. This Agreement binds and benefits the Parties and their respective successors and permitted assigns.
9.4 Severability. If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force, and the court shall reform the invalid provision to the minimum extent necessary to render it enforceable.
9.5 Entire Agreement. This Agreement constitutes the entire agreement between the Parties regarding its subject matter and supersedes all prior or contemporaneous oral or written agreements.
9.6 Counterparts; Electronic Signatures. This Agreement may be executed in multiple counterparts, each of which is deemed an original, and all of which together constitute one instrument. Signatures transmitted by facsimile or electronic means (including via DocuSign or PDF) are deemed original signatures.
9.7 Headings & Construction. Headings are for convenience only and shall not affect interpretation. “Including” means “including without limitation.” The Parties jointly drafted this Agreement, and no presumption shall arise against either Party.
9.8 Notices. All notices shall be in writing and deemed given when (i) delivered by hand with signed receipt; (ii) sent by nationally-recognized overnight courier with tracking; or (iii) deposited in the U.S. mail, certified, return-receipt requested, postage prepaid, in each case addressed to the receiving Party at the address set forth below (or as updated by notice).
9.9 Taxes. Releasor is solely responsible for any tax liability arising from the settlement proceeds, other than those of Releasee. Releasee makes no representations regarding tax consequences.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the Parties hereto have executed this Personal Injury Settlement Agreement and Mutual Release effective as of the Effective Date.
RELEASOR
[PLAINTIFF NAME]
Signature: _____
Printed Name: ____
Date: _______
RELEASEE
[DEFENDANT/INSURER NAME]
By: ______
Name: ______
Title: _____
Date: _______
[// GUIDANCE: Depending on Missouri county practice and the nature of the claimant, add a notary acknowledgment block. For minor or incapacitated claimants, include signature of the “Next Friend” or guardian, and attach the Court’s Approval Order as an Exhibit.]
11. EXHIBITS & SCHEDULES
• Exhibit A – Structured Settlement Terms (if applicable)
• Exhibit B – Court Approval Order (for Minors/Incapacitated Persons)
• Exhibit C – Stipulation of Dismissal with Prejudice
• Schedule 1 – Lien Resolution Statement
[// GUIDANCE: Remove exhibits not used. Keep numbering consistent.]
© [YEAR] [LAW FIRM OR PREPARER]. All rights reserved. This template is provided for general informational purposes and must be tailored by a licensed Missouri attorney to specific facts and circumstances.