PERSONAL INJURY SETTLEMENT AGREEMENT
AND MUTUAL RELEASE OF CLAIMS
(State of New Hampshire)
[// GUIDANCE: This template is designed for use in settling personal-injury claims arising under New Hampshire law. It presumes no arbitration and state-court venue. All bracketed items must be customized, and any optional provisions deleted if not used.]
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
1.1 Parties. This Personal Injury Settlement Agreement and Mutual Release of Claims (this “Agreement”) is entered into as of [EFFECTIVE DATE] (the “Effective Date”) by and between:
(a) [INJURED PARTY LEGAL NAME], [individual / minor / estate / business entity], with a mailing address of [ADDRESS] (“Releasor”); and
(b) [DEFENDANT LEGAL NAME], a [corporation / limited liability company / individual] with a mailing address of [ADDRESS] (“Releasee”).
1.2 Recitals.
A. An incident occurring on or about [DATE OF INCIDENT] at [LOCATION] allegedly caused personal injuries and other damages to Releasor (the “Incident”).
B. Releasor has asserted, or could assert, certain claims against Releasee arising out of or relating to the Incident (collectively, the “Action”).
C. The Parties desire to resolve fully and finally any and all claims relating to the Incident without admission of liability, upon the terms and conditions set forth herein.
D. The Parties acknowledge that good and valuable consideration supports this Agreement, the sufficiency of which is hereby acknowledged.
1.3 Governing Law & Venue. This Agreement shall be construed, interpreted, and enforced in accordance with the tort and contract laws of the State of New Hampshire, without regard to conflict-of-laws rules. Any suit, action, or proceeding arising out of or relating to this Agreement shall be brought exclusively in the state courts located in [COUNTY], New Hampshire.
II. DEFINITIONS
For purposes of this Agreement, capitalized terms have the meanings set forth below:
“Action” – the claims, causes of action, demands, and liabilities, whether known or unknown, asserted or unasserted, fixed or contingent, that Releasor has or may have against Releasee or the Releasee Parties arising out of or relating to the Incident.
“Claims” – collectively, the Action, and any other claims released in Section 7.1.
“Medicare” – the federal health-insurance program established under 42 U.S.C. § 1395 et seq.
“Party” and “Parties” – individually, Releasor or Releasee; collectively, both.
“Releasee Parties” – Releasee, its past, present, and future parents, subsidiaries, affiliates, insurers, reinsurers, officers, directors, members, managers, employees, agents, representatives, attorneys, successors, and assigns.
“Releasor Parties” – Releasor, his/her/their heirs, executors, administrators, guardians, conservators, personal representatives, successors, and assigns.
“Settlement Amount” – the monetary consideration described in Section 3.1.
“Structured Settlement” – a periodic-payment arrangement established under Section 3.2 (if applicable).
III. OPERATIVE PROVISIONS
3.1 Payment of Settlement Amount.
(a) Releasee shall pay to Releasor the total sum of [US DOLLAR AMOUNT IN WORDS] United States Dollars (US $[NUMERIC]) (the “Settlement Amount”) as follows:
(i) [LUMP-SUM COMPONENT] payable within [NUMBER] days after the later of (x) the Effective Date and (y) Releasee’s receipt of an executed copy of this Agreement and IRS Form W-9; and
(ii) [escrow / trust / direct draft], if applicable.
(b) The Settlement Amount represents the sole monetary consideration for the Releases in Section 7.1 and includes all damages, costs, attorneys’ fees, interest, and liens.
3.2 Structured Settlement (Optional).
[ ] Check if applicable. If checked:
(a) A portion of the Settlement Amount, equal to US $[STRUCTURED PORTION], shall be paid through a qualified structured-settlement annuity compliant with the Internal Revenue Code §§ 104(a)(2) and 130 and New Hampshire’s Structured Settlement Protection Act, RSA § 415-B.
(b) The annuity issuer shall be [ANNUITY COMPANY], rated at least A.M. Best “A” at the time of issuance.
(c) Periodic payments shall be made as set forth on Exhibit A (the “Payment Schedule”) and are non-accelerable, non-assignable, and non-transferable, except as permitted by RSA § 415-B and court order.
[// GUIDANCE: Delete Section 3.2 if the settlement is 100% lump-sum.]
3.3 Conditions Precedent. Payment of the Settlement Amount is expressly conditioned upon:
(a) execution of this Agreement by all Parties (and, if applicable, the natural or court-appointed guardian of any minor Releasor);
(b) delivery of any court orders approving a minor settlement under Section 3.4; and
(c) receipt of Medicare conditional-payment information sufficient to satisfy Section 7.3.
3.4 Minor Settlement Approval (if applicable).
(a) If Releasor is a minor, the Parties shall promptly seek approval of this Agreement from the [New Hampshire Circuit Court—Probate Division] pursuant to RSA §§ 464-A and any applicable local rules.
(b) Until such approval is final and non-appealable, this Agreement shall be enforceable in escrow only, and any funds tendered shall be held in trust for the benefit of the minor.
IV. REPRESENTATIONS & WARRANTIES
4.1 Mutual Representations. Each Party represents and warrants that:
(a) Authority. It has full authority and legal capacity to enter into and perform this Agreement and to grant the Releases herein.
(b) No Assignment. It has not assigned, pledged, or otherwise transferred any Claim that is the subject of this Agreement.
(c) No Reliance. It enters into this Agreement in reliance solely upon its own knowledge and the advice of its counsel, and not upon any representation by the other Party except as expressly set forth herein.
4.2 Releasor’s Additional Representations. Releasor further represents that:
(a) Understanding of Release. The Release in Section 7.1 is clear, conspicuous, and unambiguous, and Releasor understands its legal effect under New Hampshire law;
(b) Medicare / Medicaid Status. Releasor is [check one]: ☐ not enrolled in Medicare; ☐ enrolled in Medicare (HICN: [___]); ☐ unknown.
(c) Liens. All known medical or other liens are listed on Exhibit B, and Releasor shall be solely responsible for satisfaction except as otherwise stated herein.
4.3 Survival. All representations and warranties survive the Effective Date and the consummation of all transactions contemplated hereby.
V. COVENANTS & RESTRICTIONS
5.1 No Future Claims. Releasor covenants never to institute, prosecute, or voluntarily aid any suit or proceeding in law, equity, or otherwise against any Releasee Party for any Claim released under Section 7.1.
5.2 Confidentiality (Optional).
[ ] Check if applicable. If checked:
(a) The existence and terms of this Agreement shall be kept confidential and disclosed only to: counsel, tax advisors, insurers, immediate family, and as required by law or court order.
(b) Breach of confidentiality constitutes a material default subject to Section 6.2.
5.3 Non-Disparagement (Optional). Each Party agrees to refrain from making statements, whether oral or written, that would reasonably be expected to disparage the other Party or its reputation in connection with the Incident.
5.4 Notice Obligation. Each Party shall give the other written notice within five (5) business days of learning of any threatened or actual Claim, lien, or governmental inquiry that could affect the Releases or the Settlement Amount.
VI. DEFAULT & REMEDIES
6.1 Events of Default. The following constitute an “Event of Default”:
(a) failure by Releasee to deliver any portion of the Settlement Amount within the time required;
(b) material breach by either Party of Sections 5.1 or 5.2;
(c) any representation in Article IV proven to be materially false as of the Effective Date.
6.2 Cure Period. The non-defaulting Party shall give written notice specifying the default. The defaulting Party shall have ten (10) calendar days to cure monetary defaults and fifteen (15) calendar days for non-monetary defaults.
6.3 Remedies.
(a) If Releasee defaults and fails to cure, Releasor may:
(i) enforce specific performance of payment; and/or
(ii) enter judgment for the unpaid Settlement Amount plus interest at the statutory rate under RSA § 336:1.
(b) If Releasor defaults and fails to cure, the Releases in Section 7.1 shall remain effective, but Releasee may seek damages, equitable relief, or repayment of the Settlement Amount (less any liens satisfied).
6.4 Attorneys’ Fees. The prevailing Party in any proceeding to enforce this Agreement shall be entitled to recover reasonable attorneys’ fees and costs, including post-judgment and appeal.
VII. RISK ALLOCATION
7.1 Mutual Release of Claims.
(a) Releasor, for and on behalf of the Releasor Parties, hereby fully, finally, and forever releases, acquits, and discharges the Releasee Parties from any and all Claims.
(b) Releasee, for and on behalf of the Releasee Parties, releases the Releasor Parties from any and all claims arising from the Incident, including contribution and indemnity.
[// GUIDANCE: New Hampshire courts require that a release of personal-injury claims be specific and unequivocal. Do not remove Section 7.1(a).]
7.2 Limitation of Liability. The total aggregate liability of Releasee under this Agreement shall not exceed the Settlement Amount, except for obligations expressly surviving (e.g., unpaid structured-settlement funding).
7.3 Medicare Secondary Payer Compliance.
(a) Releasor acknowledges responsibility for any Medicare conditional-payment reimbursement pursuant to 42 U.S.C. § 1395y(b)(2).
(b) Releasor shall indemnify and hold harmless Releasee for any CMS claims, penalties, or interest arising from Releasor’s failure to satisfy such reimbursement obligations.
7.4 Lien Indemnification. Releasor shall indemnify, defend, and hold harmless Releasee against any healthcare, workers’ compensation, child-support, or governmental liens not disclosed on Exhibit B.
7.5 Force Majeure. No Party is liable for delay or failure in performance caused by acts of God, war, civil disturbance, epidemic, or governmental action that make performance illegal or impossible; provided, however, that payment obligations once due are not excused.
VIII. DISPUTE RESOLUTION
8.1 Governing Law. New Hampshire law governs all matters arising out of or relating to this Agreement.
8.2 Forum Selection. Each Party irrevocably submits to the exclusive jurisdiction of the state courts located in [COUNTY], New Hampshire and waives any objection based on forum non conveniens.
8.3 No Arbitration; Jury Trial. The Parties consciously elect not to submit disputes to arbitration. Nothing herein constitutes a waiver of the right to a jury trial under Part I, Article 20 of the New Hampshire Constitution; however, either Party may waive jury trial on a case-by-case basis by written stipulation.
[// GUIDANCE: Metadata specified no jury waiver, so Section 8.3 preserves jury rights.]
IX. GENERAL PROVISIONS
9.1 Entire Agreement. This Agreement, together with its Exhibits, constitutes the entire agreement of the Parties with respect to the subject matter and supersedes all prior negotiations, understandings, or agreements.
9.2 Amendments & Waivers. No amendment or waiver is binding unless in a writing signed by all Parties. A waiver of any breach is not a waiver of any other or subsequent breach.
9.3 Assignment. Neither Party may assign or delegate its rights or obligations without prior written consent of the other, except that Releasee may assign payment obligations to an annuity issuer under Section 3.2.
9.4 Severability. If any provision is held invalid or unenforceable, the remaining provisions remain in full force, and the invalid provision shall be reformed to the minimum extent necessary to achieve its original intent.
9.5 Successors & Assigns. This Agreement binds and benefits the Parties and their respective successors and permitted assigns.
9.6 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 by facsimile or electronic means (e.g., PDF, DocuSign) are effective and enforceable.
9.7 Headings. Headings are for convenience only and do not affect interpretation.
9.8 Construction. The Parties acknowledge that each has participated in drafting and that no presumption shall arise against the drafter.
X. EXECUTION BLOCK
IN WITNESS WHEREOF, the Parties have executed this Agreement as of the Effective Date.
RELEASOR
[If minor: [GUARDIAN NAME], as parent and natural guardian of [MINOR NAME]]
Signature: ____
Name: ____
Date: ________
RELEASEE
[ENTITY NAME]
By: _______
Name: ______
Title: _____
Date: _________
[OPTIONAL – NOTARIZATION]
State of New Hampshire
County of _____
On this _ day of _, 20, before me, the undersigned notary public, personally appeared _____, who proved to me through satisfactory evidence of identification to be the person whose name is signed above, and acknowledged executing the same for the purposes therein contained.
Notary Public
My Commission Expires: ______
EXHIBIT A – PAYMENT SCHEDULE (Structured Settlement)
[// GUIDANCE: Complete only if Section 3.2 is used.]
EXHIBIT B – LIEN DISCLOSURE SCHEDULE
- Medicare conditional payments: US $__
- Medicaid lien: US $__
- Private health insurer: US $__
- Workers’ compensation lien: US $__
- Child-support or other governmental liens: US $__
[// GUIDANCE: End of document. Conduct a final defined-term check before use.]