PERSONAL INJURY SETTLEMENT AGREEMENT AND MUTUAL RELEASE
(State of Nebraska)
TABLE OF CONTENTS
I. Document Header
II. Definitions
III. Operative Provisions
IV. Representations & Warranties
V. Covenants & Restrictions
VI. Default & Remedies
VII. Risk Allocation
VIII. Dispute Resolution
IX. General Provisions
X. Execution Block
I. DOCUMENT HEADER
1. Parties
This Personal Injury Settlement Agreement and Mutual Release (“Agreement”) is made and entered into as of [EFFECTIVE DATE] (the “Effective Date”) by and between:
- [CLAIMANT FULL LEGAL NAME], an individual residing at [CLAIMANT ADDRESS] (“Claimant”); and
- [DEFENDANT FULL LEGAL NAME], a [TYPE OF ENTITY / INDIVIDUAL] with a principal place of business/residence at [DEFENDANT ADDRESS] (“Defendant,” and together with Claimant, each a “Party” and collectively the “Parties”).
2. Recitals
A. On or about [DATE OF INCIDENT], Claimant allegedly sustained personal injuries at [LOCATION/EVENT] (the “Incident”).
B. Claimant contends that Defendant is legally responsible for damages arising out of the Incident; Defendant expressly denies liability.
C. The Parties desire to fully and finally settle any and all claims arising from or related to the Incident upon the terms and conditions set forth herein, intending this Agreement to be a full, final, and complete mutual release.
D. The Parties intend that this Agreement be governed by and construed in accordance with the substantive laws of the State of Nebraska.
NOW, THEREFORE, in consideration of the mutual promises, covenants, payments, and releases herein, and for other good and valuable consideration, the sufficiency of which is hereby acknowledged, the Parties agree as follows:
II. DEFINITIONS
For purposes of this Agreement, the following terms have the meanings set forth below. Defined terms may be used in the singular or plural and shall apply equally to both genders and neuter, as the context requires.
“Approved Court” means the Nebraska state court having jurisdiction to approve settlements involving minors or structured settlements, or any other court of competent jurisdiction as required by Nebraska law.
“Closing Date” means the date on which all Conditions Precedent (Section 3.4) have been satisfied or waived and Settlement Funds have been delivered.
“Conditions Precedent” has the meaning assigned in Section 3.4.
“Incident” has the meaning set forth in Recital A.
“Minor Claimant” means a Claimant who is under the age of majority under Nebraska law on the Effective Date.
“Releasees” means Defendant and each of Defendant’s past, present, and future parents, subsidiaries, affiliates, officers, directors, managers, employees, agents, insurers, reinsurers, successors, and assigns.
“Releasors” means Claimant and each of Claimant’s past, present, and future spouses, heirs, beneficiaries, executors, administrators, agents, insurers, reinsurers, representatives, successors, and assigns.
“Settlement Amount” means the total consideration described in Section 3.2, inclusive of all attorney fees, costs, liens, subrogation interests, and future medical expenses, unless otherwise expressly stated.
“Structured Settlement” means any agreed periodic payment arrangement consistent with Nebraska Structured Settlement Protection requirements.
“Unknown Injuries” means injuries, damages, or losses of any nature that Claimant does not know or suspect to exist on the Effective Date, which if known might have materially affected Claimant’s decision to enter this Agreement.
III. OPERATIVE PROVISIONS
3.1 Mutual Release
Subject to the performance of obligations herein, Releasors hereby irrevocably and unconditionally release, acquit, and forever discharge Releasees from any and all past, present, and future claims, causes of action, demands, rights, liabilities, obligations, damages, costs, losses, or expenses of any nature whatsoever, whether known or Unknown, arising from or related to the Incident (“Released Claims”). Defendant, on behalf of itself and its affiliates, likewise releases Claimant and Releasors from all claims arising from or related to the Incident.
[// GUIDANCE: Nebraska recognizes releases of Unknown Injuries where the intent to do so is expressed in clear, unequivocal language—this clause is drafted accordingly.]
3.2 Consideration
a. Lump-Sum Settlement: Defendant shall pay Claimant the total gross sum of [US $__] (“Settlement Amount”) on or before the Closing Date.
b. Structured Settlement (if elected): In lieu of, or in addition to, the lump-sum payment, the Parties agree to the Structured Settlement schedule attached hereto as Exhibit A. All periodic payments shall be funded through a qualified assignment and annuity contract compliant with applicable federal tax law and Nebraska Structured Settlement Protection requirements.
c. Allocation: Unless otherwise required by law or agreed in writing, the Settlement Amount shall be allocated [DESCRIBE ALLOCATION BETWEEN ECONOMIC/NON-ECONOMIC DAMAGES, IF ANY].
3.3 Delivery of Settlement Funds
All payments shall be made by wire transfer or cashier’s check payable to [CLAIMANT’S COUNSEL TRUST ACCOUNT / CLAIMANT], subject to customary trust accounting procedures.
3.4 Conditions Precedent
The following are conditions precedent (“Conditions Precedent”) to the Parties’ obligations:
1. Execution of this Agreement by all Parties;
2. Receipt of properly executed W-9 and any required lien waivers;
3. If applicable, written approval by the Approved Court for (i) Minor Claimant settlements and/or (ii) Structured Settlements;
4. Delivery of a signed Medicare/Medicaid Certification as described in Section 7.4.
Failure of any Condition Precedent by [DATE], absent written waiver, shall render this Agreement voidable at the non-breaching Party’s option.
3.5 No Admission of Liability
Nothing in this Agreement constitutes or shall be construed as an admission of liability, which liability is expressly denied.
IV. REPRESENTATIONS & WARRANTIES
Each Party represents and warrants as of the Effective Date that:
4.1 Authority. It has full legal right, power, and authority to execute, deliver, and perform this Agreement; and the person signing on its behalf is duly authorized.
4.2 No Assignment. It has not assigned or transferred any claim or right that is the subject of this Agreement.
4.3 Independent Counsel. It has had the opportunity to consult with counsel of its choice, and enters this Agreement freely and voluntarily.
4.4 No Reliance. In executing this Agreement, it does not rely on any representation or statement not expressly set forth herein.
4.5 Medicare/Medicaid. It has satisfied (or will satisfy) all obligations, if any, under the Medicare Secondary Payer Act and Nebraska Medicaid statutes, and no conditional payments remain unpaid except as set forth in Schedule 1.
All representations and warranties shall survive the Closing Date.
V. COVENANTS & RESTRICTIONS
5.1 Court Approval for Minors. If Claimant is a Minor Claimant, the Parties shall promptly file a petition for court approval of this settlement in accordance with Nebraska law, and shall cooperate to secure such approval. Payments to a Minor Claimant shall be paid to a court-appointed conservator or placed in a restricted account, as ordered by the court.
5.2 Confidentiality (Optional). Except to the extent required by law, court order, taxation, or lien resolution, the Parties agree to keep the terms of this Agreement confidential.
5.3 Non-Disparagement. The Parties shall refrain from making disparaging statements regarding the Incident or the Released Claims.
5.4 Further Assurances. Each Party shall execute and deliver such documents and take such further actions as may be reasonably necessary to effectuate the purposes of this Agreement.
VI. DEFAULT & REMEDIES
6.1 Events of Default. An “Event of Default” occurs if either Party fails to perform any material obligation under this Agreement within [10] business days after receipt of written notice of such failure.
6.2 Cure Period. The breaching Party shall have [10] business days following receipt of notice to cure the Event of Default.
6.3 Remedies. Upon uncured Event of Default:
a. Specific Performance. The non-breaching Party may seek specific performance or injunctive relief in Nebraska state court;
b. Monetary Damages. The non-breaching Party may recover monetary damages, including interest at the statutory rate from the date due until paid; and
c. Attorney Fees. The prevailing Party shall be entitled to recover reasonable attorney fees and costs incurred in enforcing this Agreement.
VII. RISK ALLOCATION
7.1 Mutual Release. As set forth in Section 3.1, the release is mutual and comprehensive.
7.2 Limitation of Liability. Each Party’s aggregate liability for any breach of this Agreement shall not exceed the Settlement Amount actually paid or received, except for willful misconduct or fraud.
7.3 Indemnification for Liens.
a. Claimant’s Indemnification. Claimant shall indemnify and hold harmless Releasees from any Medicare, Medicaid, workers’ compensation, medical provider, or third-party lien claims arising from the Incident, except to the extent such liens are expressly satisfied from the Settlement Amount.
b. Defendant’s Indemnification. Defendant shall indemnify and hold harmless Claimant from third-party contribution or indemnity claims arising from the Incident that are asserted by Releasees’ indemnitees.
7.4 Medicare/Medicaid Compliance.
Claimant certifies compliance with 42 U.S.C. § 1395y(b) (Medicare Secondary Payer Act) and applicable Nebraska Medicaid provisions and shall execute a certification in the form attached as Exhibit B.
7.5 Force Majeure.
Neither Party shall be liable for delay or failure in performance caused by events beyond its reasonable control, provided that such Party gives prompt notice and resumes performance as soon as practicable.
VIII. DISPUTE RESOLUTION
8.1 Governing Law. This Agreement shall be governed by the substantive laws of the State of Nebraska without regard to its conflict-of-law principles.
8.2 Forum Selection. Any action to enforce or interpret this Agreement shall be brought exclusively in the state courts located in [COUNTY], Nebraska.
8.3 Jury Waiver. The Parties acknowledge that Nebraska law disfavors advance waiver of constitutional jury-trial rights; therefore, no jury waiver is included herein.
8.4 Arbitration. The Parties affirmatively elect not to submit disputes to arbitration.
8.5 Injunctive Relief. No injunctive relief is anticipated; however, specific performance under Section 6.3(a) may be sought as equitable relief.
IX. GENERAL PROVISIONS
9.1 Entire Agreement. This Agreement constitutes the entire understanding among the Parties and supersedes all prior negotiations or agreements.
9.2 Amendments. No amendment or modification shall be effective unless in writing signed by all Parties.
9.3 Waiver. No waiver of any right shall be effective unless in writing and shall not be deemed a waiver of any subsequent breach.
9.4 Assignment. No Party may assign or delegate its rights or duties without the prior written consent of the other Party, except that Defendant may assign payment obligations to a qualified assignee solely for Structured Settlement funding.
9.5 Severability. If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force and effect, and the invalid provision shall be reformed to the minimum extent necessary to make it enforceable.
9.6 Successors & Assigns. This Agreement shall bind and benefit the Parties and their respective successors and permitted assigns.
9.7 Counterparts; Electronic Signatures. This Agreement may be executed in counterparts, each of which is deemed an original, and all of which together constitute one instrument. Signatures delivered via electronic means shall be deemed original and binding.
X. EXECUTION BLOCK
IN WITNESS WHEREOF, the Parties hereto have executed this Personal Injury Settlement Agreement and Mutual Release as of the Effective Date.
CLAIMANT
[CLAIMANT NAME]
Date: _________
DEFENDANT
By: _____
Name: _____
Title: ______
Date: _________
[OPTIONAL NOTARY ACKNOWLEDGMENT—Nebraska]
State of Nebraska )
: ss.
County of ____ )
On this _ day of _, 20__, before me, the undersigned Notary Public, personally appeared ____, known to me or satisfactorily proven to be the person(s) whose name(s) are subscribed to the within instrument and acknowledged that he/she/they executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
Notary Public
My Commission Expires: ____
EXHIBIT A
Structured Settlement Payment Schedule
[Attach insurer/annuity details, payment dates, and amounts]
EXHIBIT B
Medicare/Medicaid Certification Form
[Attach standard CMS-compliant certification]
SCHEDULE 1
Lien Summary and Resolution Plan
[Detail any known liens and how they will be satisfied]
[// GUIDANCE: Practitioners should confirm Nebraska county-specific minor-settlement procedures, verify Medicaid lien satisfaction, and ensure that any structured settlement assignment complies with federal tax requirements (I.R.C. § 130) and Nebraska’s Structured Settlement Protection statutes before closing.]