Personal Injury Settlement Agreement - Nebraska

PERSONAL INJURY SETTLEMENT AGREEMENT AND RELEASE

This Agreement is made on [DATE] between [CLAIMANT LEGAL NAME] of [ADDRESS] (“Claimant”) and [DEFENDANT LEGAL NAME] of [ADDRESS] (“Defendant”). Each is a “Party.”

1. Incident and disputed claim

The dispute concerns the incident on [DATE] at [LOCATION]: [BRIEF DESCRIPTION]. Claimant asserts [DESCRIBE INJURY AND CLAIM]. Defendant disputes liability and enters this Agreement to resolve the identified dispute without admitting fault. The pending case, if any, is [COURT, CASE NUMBER / NONE].

2. Capacity and required approval

Claimant signs ☐ personally ☐ through [REPRESENTATIVE NAME AND CAPACITY]. The Parties identify any approval required for this particular Claimant or settlement as follows: [AUTHORITY, COURT, CASE NUMBER, AND REQUIRED ORDER / NONE IDENTIFIED]. If approval is required, this Agreement and the release in Section 5 become effective only when the required order is entered and any conditions in that order are satisfied. The signed order shall be attached as Exhibit A. The Parties shall cooperate in submitting the agreement and supporting materials required by that process. No payment to a representative or account is authorized solely by this Agreement if an applicable order specifies another recipient or method.

3. Settlement consideration and payment

Defendant shall pay a total gross settlement of $[AMOUNT] in exchange for the release in Section 5. Payment shall be made by [WIRE / CHECK / OTHER] to [PAYEE AND ACCOUNT OR DELIVERY ADDRESS] no later than [DATE OR NUMBER OF DAYS AFTER FINAL SIGNATURE AND ANY REQUIRED APPROVAL].

☐ The consideration is a single payment.

☐ The consideration includes periodic payments under the complete schedule attached as Exhibit B, identifying every amount, due date, payor, funding source, and any guarantee. If this option is selected, the Parties shall specify which payment or funding acts must occur before the release takes effect: [PRECISE CONDITIONS].

The Parties shall list any proposed direct payments or holdbacks in Schedule 1. A person who has not signed this Agreement is not made a party to it by being listed as a proposed payee.

4. Recovery interests and disbursement

Before disbursement, the Parties shall complete Schedule 1 for each known asserted medical-provider, Medicare, Medicaid, workers' compensation, benefit-plan, insurer, attorney, governmental, or other recovery interest. Each entry shall identify the claimant, basis and status of the demand, amount asserted, proposed payment or holdback, person responsible for communicating and resolving it, and evidence of resolution. A disputed or unknown amount shall be labeled as such.

The Parties' allocation in Schedule 1 governs only their obligations to each other. It does not purport to release a claim held by a person or agency that is not a party to this Agreement. No blanket indemnity is created. Any claim-specific indemnity must be separately written and signed, identifying the exact claim, protected person, notice, control of defense and settlement, exclusions, and amount or measure of liability.

5. Release and reserved rights

Releasees: [LIST EACH PERSON OR ENTITY BY LEGAL NAME]. Released claims: [IDENTIFY CLAIM TYPES AND INCIDENT DATE RANGE]. Scope of injuries: ☐ identified known injuries only ☐ identified known and unknown injuries arising from the Incident. Reserved claims, benefits, liens, reimbursement rights, and persons: [DESCRIBE / NONE].

Upon final receipt of the consideration and satisfaction of any approval and funding condition in Sections 2 and 3, Claimant releases only the named Releasees from only the Released Claims. Claimant does not purport to release a claim owned independently by an heir, spouse, insurer, agency, or other person who has not signed this Agreement in that capacity. The release does not cover a later breach of this Agreement.

☐ Optional reciprocal release: Upon the same conditions, Defendant releases Claimant from the following identified claims: [DESCRIBE / NONE]. If this box is not checked, Defendant grants no reciprocal release.

6. Pending action and documents

If a case is pending, the Parties shall prepare and submit an agreed dismissal or other required filing within [NUMBER] days after the release becomes effective, consistent with any court order. Neither Party shall file a document stating that payment or approval has occurred before it has occurred. The Parties shall exchange reasonably necessary receipts and release documents to complete the agreed closing.

7. Representations

Each signatory represents that the signatory has authority to sign in the stated capacity, has disclosed any prior assignment of the Released Claims in [ATTACHED LIST / “NONE”], and has had an opportunity to consult independent counsel. Claimant's statement of known recovery interests is set out in Schedule 1; it is not a certification that no other person can assert a claim.

8. Nonpayment and other breach

A Party claiming material breach shall give written notice describing it to the other Party at the address in Section 10, with [NUMBER] days to remedy if the breach can be remedied. If Defendant does not make a required payment by the agreed date and no written extension is signed, the Section 5 release does not take effect for any unpaid consideration. A Party may seek relief available under governing law for an uncured breach. This Agreement creates no automatic prevailing-party fee, statutory-interest rate, specific-performance entitlement, or cap on liability for breach.

9. Other terms

No admission. This settlement is a compromise of disputed claims and is not an admission of fault.

Confidentiality. ☐ No confidentiality promise. ☐ The Parties will keep the settlement amount confidential except for disclosures to counsel, tax advisers, insurers, lien or recovery claimants, agencies, courts, or as required by law. Select one.

Governing law and forum. Nebraska law governs this Agreement. Any enforcement action shall be filed in a court with jurisdiction and proper venue. This Agreement does not waive a jury-trial right or require arbitration.

Later transfer of structured payments. If Exhibit B creates structured settlement payment rights, any later proposed transfer is a separate transaction; Neb. Rev. Stat. § 25-3105 addresses the court application for authorization of such a transfer. This Agreement does not itself approve a later transfer.

Entire agreement and changes. This Agreement, its completed schedules, and any required court order state the Parties' agreement about the Released Claims. A change must be in a writing signed by the affected Parties. An unenforceable provision may be severed to the extent permitted by law without expanding the release.

Signatures. Counterparts and electronic signatures may be used where permitted by applicable law and agreed by the Parties. Each Party shall receive a complete signed copy with all completed schedules.

10. Notice addresses

Claimant notice address and email, if agreed: [ADDRESS AND EMAIL / PAPER ONLY]

Defendant notice address and email, if agreed: [ADDRESS AND EMAIL / PAPER ONLY]

Agreed delivery method for contractual breach notices: [PERSONAL DELIVERY / MAIL / CONSENTED EMAIL]

11. Signatures

Exhibit A — Required approval order

[ATTACH SIGNED ORDER, IF REQUIRED; OTHERWISE WRITE “NOT APPLICABLE.”]

Exhibit B — Periodic payment and funding schedule

[ATTACH COMPLETE SCHEDULE IF SELECTED IN SECTION 3; OTHERWISE WRITE “NOT APPLICABLE.”]

Schedule 1 — Recovery interests, payments, and holdbacks