PERSONAL INJURY SETTLEMENT AND RELEASE AGREEMENT
(New Jersey – Court-Ready Template)
[// GUIDANCE: This template is drafted to comply with New Jersey tort law, the N.J. Structured Settlement Protection Act, and N.J. Ct. R. 4:44 & 4:44A governing minor or incapacitated-person settlements. Bracketed text must be customized before execution.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
PERSONAL INJURY SETTLEMENT AND MUTUAL RELEASE AGREEMENT
This Personal Injury Settlement and Mutual Release Agreement (this “Agreement”) is made and entered into as of [EFFECTIVE DATE] (the “Effective Date”) by and between:
• [FULL LEGAL NAME OF INJURED PARTY], [individual | minor | incapacitated person], residing at [ADDRESS] (“Releasor”); and
• [FULL LEGAL NAME OF DEFENDANT(S)/INSURER(S)], a [state] [entity type], with principal offices at [ADDRESS] (“Releasee,” and together with its past, present, and future parents, subsidiaries, affiliates, officers, directors, shareholders, employees, agents, insurers, heirs, successors, and assigns, collectively, the “Released Parties”).
Recitals
A. On or about [INCIDENT DATE], Releasor allegedly sustained personal injuries and other damages arising out of [BRIEF DESCRIPTION OF ACCIDENT/INCIDENT] (the “Incident”).
B. Disputes have arisen between the Parties regarding liability for, and the nature and extent of, Releasor’s alleged injuries and damages (the “Claims”).
C. Without admitting liability, the Parties desire to fully, finally, and forever settle the Claims on the terms set forth herein for good and valuable consideration, the sufficiency of which is hereby acknowledged.
NOW, THEREFORE, in consideration of the mutual covenants, promises, and payments set forth herein, the Parties agree as follows:
2. DEFINITIONS
For purposes of this Agreement, the following terms shall have the meanings set forth below. Defined terms appear alphabetically and apply throughout the Agreement.
“Agreement” has the meaning set forth in the preamble.
“Claims” has the meaning set forth in Recital B.
“CMS” means the Centers for Medicare & Medicaid Services.
“Court Approval” means an order issued pursuant to N.J. Ct. R. 4:44 or 4:44A approving settlement of a claim by or on behalf of a minor or incapacitated person.
“Effective Date” has the meaning set forth in the Document Header.
“Incident” has the meaning set forth in Recital A.
“Medicare Program” means Title XVIII of the Social Security Act, 42 U.S.C. §§ 1395–1395lll.
“Parties” means, collectively, Releasor and Releasee; “Party” refers to either of them.
“Released Parties” has the meaning set forth in the Document Header.
“Settlement Amount” means the total monetary consideration described in Section 3.1.
[// GUIDANCE: Add or delete definitions as necessary.]
3. OPERATIVE PROVISIONS
3.1 Settlement Consideration
a. Lump-Sum Payment. Within [NUMBER] business days after the later of (i) the Effective Date and (ii) satisfaction of all Conditions Precedent in Section 3.4, Releasee shall pay to Releasor, or to [LAW FIRM TRUST/IOLTA ACCOUNT], the sum of [US$ __] (the “Settlement Amount”) by [wire transfer | draft].
b. Structured Settlement (if applicable). In lieu of, or in addition to, the lump-sum payment, the Parties agree to the structured settlement annuity schedule set forth on Exhibit A (the “Structured Payments”). Releasee shall irrevocably fund the annuity through a qualified assignment compliant with the Internal Revenue Code § 130 and the New Jersey Structured Settlement Protection Act, N.J. Stat. Ann. §§ 2A:xx-xx to xx-xx (the “SSPA”).
[// GUIDANCE: Delete 3.1(b) if no structure is contemplated.]
3.2 Mutual Release of Claims
a. Releasor’s Release. Upon receipt of the Settlement Amount and any Structured Payments, Releasor, on behalf of himself/herself and all heirs, administrators, representatives, successors, and assigns, irrevocably and unconditionally releases and forever discharges the Released Parties from any and all past, present, or future claims, demands, causes of action, obligations, damages, costs, expenses, and liabilities of every kind, whether known or unknown, foreseen or unforeseen, that arise out of or relate in any way to the Incident or the Claims, including but not limited to all claims for personal injury, pain and suffering, lost wages, medical expenses, liens, attorney’s fees, and punitive damages (“Released Claims”).
b. Releasee’s Release. Upon the Effective Date, Releasee, on behalf of itself and the other Released Parties, releases and forever discharges Releasor from any and all claims arising out of or relating to the Incident or the Claims, excluding enforcement of this Agreement.
c. Unknown Claims Waiver. Releasor expressly waives the protections of any statute or common-law doctrine limiting the release of claims unknown to a releasing party at the time of execution.
3.3 No Admission of Liability
This Agreement is a compromise of disputed claims and shall not be construed as an admission of liability, fault, or wrongdoing by any Party, which is expressly denied.
3.4 Conditions Precedent
The following are conditions precedent to Releasee’s payment obligations:
1. Receipt of a fully executed Agreement.
2. If Releasor is a minor or incapacitated person, entry of a Court Approval order.
3. Delivery to Releasee of a properly executed Stipulation of Dismissal with Prejudice for filing in [COURT NAME, DOCKET NO.].
4. Completion of Medicare/Medicaid lien resolution in accordance with Section 5.3.
3.5 Dismissal of Litigation
Within [NUMBER] business days after Releasee fulfills Section 3.1, the Parties shall file the Stipulation of Dismissal with Prejudice in the action identified above, each party to bear its own costs.
4. REPRESENTATIONS & WARRANTIES
Each Party represents and warrants, as applicable, that:
4.1 Authority. It has full power and authority to enter into and perform this Agreement and to grant the releases provided herein.
4.2 No Assignment. No claims released herein have been sold, assigned, subrogated, or otherwise transferred to any third party.
4.3 Legal Counsel. It has had the opportunity to consult with independent legal counsel of its choice, and enters into this Agreement voluntarily, without coercion or duress.
4.4 Accuracy of Information. All information provided in connection with lien resolution, medical expenses, and damages is true, complete, and accurate to the best of its knowledge.
4.5 Survival. The representations and warranties in this Section 4 shall survive the Effective Date.
5. COVENANTS & RESTRICTIONS
5.1 Confidentiality. Except as required by law or court order, the Parties shall keep the terms of this Agreement and the amount of the Settlement Amount confidential.
5.2 Non-Disparagement. The Parties shall refrain from making any statement, written or oral, that could reasonably be construed to disparage the other Party concerning the Incident or this settlement.
5.3 Medicare/Medicaid Compliance. Releasor shall satisfy and hold Releasee harmless from any conditional payments, liens, or reimbursement obligations owed to CMS under the Medicare Secondary Payer Act or to any state Medicaid program. The Parties shall cooperate to report this settlement to CMS under Section 111 of the Medicare, Medicaid, and SCHIP Extension Act, 42 U.S.C. § 1395y(b)(8).
5.4 SSPA Non-Transfer Covenant. Releasor shall not assign, accelerate, or encumber any Structured Payments without first obtaining court approval in compliance with the SSPA.
5.5 Further Assurances. Each Party shall execute and deliver any additional documents reasonably necessary to carry out the purposes of this Agreement.
6. DEFAULT & REMEDIES
6.1 Event of Default. Failure by either Party to perform any material obligation under this Agreement within [10] business days after written notice shall constitute an “Event of Default.”
6.2 Remedies.
a. Monetary Default by Releasee. Releasor may enforce payment, plus interest at the New Jersey post-judgment rate from the due date until paid.
b. Breach of Confidentiality or Non-Disparagement. The non-breaching Party may seek damages and injunctive relief in the Superior Court of New Jersey, without the necessity of posting bond.
c. Attorney’s Fees. The prevailing Party in any action to enforce this Agreement shall be entitled to reasonable attorney’s fees and costs.
6.3 Cumulative Remedies. All rights and remedies are cumulative and non-exclusive.
7. RISK ALLOCATION
7.1 Indemnification.
a. By Releasor. Releasor shall indemnify, defend, and hold harmless the Released Parties from any and all liens, claims, or actions asserted by any third party (including governmental authorities) arising from medical expenses, subrogation claims, or other interests related to the Incident.
b. By Releasee. Releasee shall indemnify, defend, and hold harmless Releasor from claims brought by the Released Parties that are inconsistent with the release granted herein.
7.2 Limitation of Liability. The Released Parties’ aggregate liability under this Agreement shall not exceed the Settlement Amount and any Structured Payments expressly set forth herein.
7.3 Insurance. Releasee represents that liabilities released herein are covered by policy no. [POLICY NUMBER] issued by [INSURER] and that such insurer consents to this settlement.
7.4 Force Majeure. No Party shall be liable for delay or failure in performance due to acts of God, war, terrorism, or other causes beyond its reasonable control; provided, however, that payment obligations shall not be excused.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Agreement shall be governed by and construed in accordance with the internal laws of the State of New Jersey without regard to conflict-of-law principles.
8.2 Forum Selection. The Parties submit to the exclusive jurisdiction of the Superior Court of New Jersey, [COUNTY] Vicinage, and waive any objection to venue or forum non conveniens.
8.3 Arbitration. The Parties expressly agree that no arbitration provisions apply.
8.4 Jury Trial. Nothing herein constitutes a waiver of any constitutional right to trial by jury.
9. GENERAL PROVISIONS
9.1 Entire Agreement. This Agreement constitutes the entire understanding of the Parties and supersedes all prior negotiations or agreements, oral or written, relating to the subject matter.
9.2 Amendments and Waivers. No amendment or waiver of any provision shall be effective unless in writing and signed by all Parties.
9.3 Assignment. No Party may assign or delegate its rights or obligations under this Agreement without the prior written consent of the other Party, except to successors by merger or operation of law.
9.4 Severability. If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force, and the invalid provision shall be reformed to the minimum extent necessary to render it valid.
9.5 Successors and Assigns. This Agreement binds and benefits the Parties and their respective heirs, executors, administrators, successors, and permitted assigns.
9.6 Counterparts; Electronic Signatures. This Agreement may be executed in any number of counterparts, each of which is deemed an original, and all of which constitute one instrument. Signatures transmitted by facsimile or electronic means (e.g., PDF, DocuSign) shall be deemed originals.
9.7 Headings. Section headings are for convenience only and shall not affect interpretation.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the Parties have executed this Agreement as of the Effective Date.
RELEASOR
[NAME]
Date: ________
[// GUIDANCE: If Releasor is a minor or incapacitated person, insert guardian information and attach Court Approval order once obtained.]
RELEASEE
[AUTHORIZED SIGNATORY NAME]
[Title], [Entity Name]
Date: ________
NOTARIZATION (if required)
State of New Jersey
County of [__]
On this _ day of _, 20__, before me, the undersigned Notary Public, personally appeared [NAME], satisfactorily proven to be the person whose name is subscribed to this instrument, and acknowledged that he/she executed the same for the purposes therein contained.
Notary Public
My Commission Expires: ______
EXHIBIT A – STRUCTURED PAYMENT SCHEDULE
[// GUIDANCE: Insert payment dates, amounts, and designated payee information in compliance with IRC § 130 and the SSPA.]
[// GUIDANCE: Prior to client use, verify all bracketed information, confirm lien resolution status, and ensure Court Approval procedures (if applicable) are calendared. Consider preparing a separate Qualified Assignment and an annuity contract endorsement to accomplish the structured settlement.]