Personal Injury Settlement Agreement - North Carolina

PERSONAL INJURY SETTLEMENT AGREEMENT AND RELEASE

(North Carolina)

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

The disputed claim arises from an incident on [DATE] 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, lien, and dismissal schedules.

2. Defined Settlement Scope

“Approval Order” means any court or administrative order that counsel determines is required and 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. Category labels must be reviewed deliberately and do not replace a complete list.

“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 Payment allocation. Exhibit C states every payee, amount or reserve, method, deadline, escrow condition, lien or reimbursement holdback, attorney fee and cost, and any court-restricted or trust 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 be documented in Exhibit C after advisor review.

4. Conditions and Effective Date

Select every applicable condition:

• ☐ Signature by all Parties and required representatives
• ☐ Entry of the Approval Order in Exhibit D
• ☐ Delivery of dismissal papers to escrow
• ☐ Final medical-provider lien figures or agreed holdbacks under Exhibit C
• ☐ Final Medicaid amount, agreement, court allocation process, or holdback under Exhibit C
• ☐ Final Medicare, benefit-plan, insurer, workers' compensation, child-support, or other recovery-interest process under Exhibit C
• ☐ 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 fiduciary, represents an estate, or otherwise may require approval, Exhibit D must identify:

• the correct proceeding and court or authority;
• each representative's appointment and scope of authority;
• any guardian ad litem or independent-review requirement;
• the petition, notice, hearing, findings, allocation, restricted-account, bond, trust, or distribution terms;
• the order that must be entered before the release or funding becomes effective.

No statute, $5,000 threshold, guardian role, account restriction, or notarial requirement should be inferred from this form. Counsel must insert the current authority and exact order terms in Exhibit D.

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 costs and fees are allocated as follows: [TERMS].

7. Medical-Provider Liens and Medicaid

7.1 Provider liens. North Carolina General Statutes §§ 44-49 and 44-50 create and regulate specified liens against personal-injury recoveries. Exhibit C must record for each asserted lien:

The disbursing person must not rely on a claimant instruction that conflicts with Article 9. Counsel must apply § 44-50's attorney-fee treatment, priority rules, and fifty-percent lien limit to the completed facts rather than copying a gross-payment promise into the release.

7.2 Medicaid. If § 108A-57 applies, Exhibit C must identify the Department and any designated prepaid health plan, payments included in the Medicaid claim, gross recovery, statutory presumption, any negotiated amount, and any court application.

• ☐ No allocation application will be filed; counsel calculated the payment and deadline.
• ☐ An application disputing the presumption will be filed and served within the statutory 30-day period.
• ☐ Department/designated-plan agreement attached.
• ☐ Notice of receipt of proceeds and distribution deadlines calendared.

7.3 Other interests. Exhibit C must separately inventory and assign responsibility for every asserted Medicare, insurer, benefit-plan, State Health Plan, workers' compensation, child-support, attorney, funding-company, assignment, subrogation, reimbursement, or other payment interest. No blanket representation that “no liens exist” or blanket indemnity applies unless the facts and identified claim justify it.

8. Release and Reserved Claims

8.1 Claimant release. 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 Other alleged tortfeasors. Exhibit A states whether claims against every nonsettling person are reserved and how settlement credit, contribution, indemnity, or allocation issues are handled after counsel review.

8.5 No admission. 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, required approval, tax and benefit reporting, lien and reimbursement 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 lien, 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 / AUTHORITY]
• ☐ 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, 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, lien, dismissal, or confidentiality duties unless the Parties insert a specific counsel-reviewed clause here: [TERMS].

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. There is no general claimant or mutual indemnity.

12. Governing Law and Disputes

North Carolina 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 any 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 law.

13. General Terms

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

13.2 Amendments. An amendment or waiver must be in a record signed by every affected Party and approved through any process required by an Approval Order or governing law.

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

13.4 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.

13.5 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, heir, estate, insurer, successor, or assignee.

13.6 Counterparts and signatures. The Parties select:

• ☐ Counterpart and electronic signatures under the completed signing protocol: [TERMS].
• ☐ Wet-ink originals required for: [DOCUMENTS].

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

14. Signatures

CLAIMANT / RELEASOR

Signature: ______________________________

Name: [NAME]

Date: [DATE]

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

DEFENDANT / RELEASEE

Signature: ______________________________

Name and title: [NAME / TITLE]

Date: [DATE]

OTHER REQUIRED PARTY

Signature: ______________________________

Name, capacity, and authority: [DETAILS]

Date: [DATE]

Use a notarial certificate only if counsel, the Approval Order, escrow, or another applicable requirement calls for one.

15. Exhibits

• Exhibit A — Released Parties, Released Claims, Reserved Claims, Other Alleged Tortfeasors
• Exhibit B — Funding, Periodic Payments, Assignment, Annuity, and Beneficiary Terms
• Exhibit C — Payment Allocation, Fees, Costs, Liens, Medicaid, Other 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