Personal Injury Settlement Agreement - New Jersey

NEW JERSEY PERSONAL INJURY SETTLEMENT AGREEMENT

This Agreement is made on [__/__/____] between [CLAIMANT FULL NAME], an adult signing personally ("Claimant"), and [SETTLING DEFENDANT FULL NAME] ("Settling Party"). The person or entity funding the settlement is [PAYOR FULL NAME] ("Payor"). If Payor differs from Settling Party, Payor also signs this Agreement.

1. Incident and pending matter

Incident date and location: [__/__/____] at [STREET / MUNICIPALITY / COUNTY, NEW JERSEY].

Description of the incident and disputed injury or loss: [________________________________]

Claim number, if any: [________________________________]

Pending court action, if any: [COURT, COUNTY, DOCKET NUMBER, CASE CAPTION / NONE]

The parties wish to resolve only the claims arising from this incident as stated below. Payment and signing are not admissions of fault or liability.

2. Settlement payment

Payor shall pay Claimant $[TOTAL AMOUNT] by [CHECK / ELECTRONIC TRANSFER / OTHER] to [PAYEE AND DELIVERY DETAILS]. Payment is due on [__/__/____] or within [NUMBER] days after [SPECIFIED EVENT].

If payment is to be made in installments, attach a signed schedule stating each amount, due date, payee, and funding method. If no signed schedule is attached, the entire amount is due as stated above. A proposed annuity or assignment is not part of this Agreement unless its exact terms are attached and signed by the parties.

A payment is received for purposes of this Agreement when the funds have cleared for the designated payee. If Payor fails to pay as agreed, Claimant may seek the unpaid amount. The release in Section 3 will not take effect until the full settlement amount has been received.

3. Claimant's release

Upon full receipt of the settlement payment, Claimant releases only the following persons or entities, each identified by legal name ("Released Parties"):

The release covers Claimant's civil claims for personal injury, property damage, expenses, and other loss arising from the incident in Section 1, within the scope selected here:

☐ All of Claimant's incident-related civil claims, including presently unknown injuries.

☐ Only these incident-related civil claims: [________________________________]

Claims or persons expressly reserved: [NONE / DESCRIBE].

The release excludes conduct occurring after its effective date and any claim to enforce this Agreement. Claimant makes no promise on behalf of a person who does not sign this Agreement. No person or entity omitted from the table above receives the release.

4. Other claims and liens

Any asserted Medicare, Medicaid, medical-provider, benefit-plan, insurer, attorney, or other reimbursement interest will be identified and handled under this completed schedule. The parties will state the basis and status of each claim, who communicates with the claimant, what amount is withheld, and who pays it.

Additional reporting or proof to be provided: [________________________________]

The parties will resolve each third-party reimbursement request through the stated process. This Agreement allocates duties between its signers; it does not speak for a third party.

5. Pending lawsuit

☐ No lawsuit about the incident is pending.

☐ After full payment clears, Claimant and Settling Party will sign and submit the agreed dismissal papers in the action identified in Section 1 within [NUMBER] days. The dismissal will identify the claims and parties it covers: [________________________________].

No dismissal paper will be filed before the full settlement payment clears unless the parties separately agree in a signed writing to an escrow or other funding procedure: [________________________________].

6. Statements and further acts

Claimant confirms that Claimant is an adult, has read this Agreement, understands the incident-specific release, and signs voluntarily after having the opportunity to consult counsel.

Claimant states whether any claim covered by Section 3 has been assigned: ☐ No assignment ☐ Assignment disclosed here: [________________________________].

Each person signing for an entity states that person's title and authority below. The parties will sign documents reasonably needed to make the specified payment, release, and dismissal effective, consistent with this Agreement.

Each party pays that party's own attorney fees and expenses unless the following different allocation is completed: [________________________________].

7. Default, changes, and governing law

A party seeking performance shall give the other signing party written notice describing the missed obligation at the address below. The receiving party has [NUMBER] days after receipt to perform, unless a different time is written here: [________________________________].

A party may seek enforcement of this Agreement in a court that has jurisdiction. New Jersey law governs. Any change to payment, the Released Parties, or the claims covered must be in a writing signed by Claimant, Settling Party, and Payor if Payor's duties change.

Notice addresses and delivery methods:

Additional agreed terms or signed exhibits: [________________________________]

8. Signatures

Claimant

Signature: ______________________________ Date: [__/__/____]

Printed name: [________________________________]

Settling Party

Signature: ______________________________ Date: [__/__/____]

Printed name: [________________________________]

Title and entity, if applicable: [________________________________]

Payor, if different from Settling Party

Signature: ______________________________ Date: [__/__/____]

Printed name: [________________________________]

Title and entity: [________________________________]