Personal Injury Settlement Agreement - New York

PERSONAL INJURY SETTLEMENT AGREEMENT AND RELEASE

(New York)

TABLE OF CONTENTS

1. Parties, Claim, and Action
2. Settlement Consideration
3. Closing Documents and Prompt Payment
4. Discontinuance of Pending Action
5. Release
6. Liens, Reimbursement Claims, and Allocations
7. Infant or Incapacitated Claimant
8. Optional Structured Payments
9. Confidentiality and Non-Disparagement Options
10. Nonpayment and Other Enforcement
11. General Provisions
12. Signatures

1. PARTIES, CLAIM, AND ACTION

This Personal Injury Settlement Agreement and Release (the “Agreement”) is made as of [DATE] by and between:

Claimant: [FULL LEGAL NAME], residing at [ADDRESS] (“Claimant”); and

Settling Defendant: [FULL LEGAL NAME / ENTITY], with an address at [ADDRESS] (“Settling Defendant”).

Insurer or payment administrator, if any: [NAME AND ADDRESS].

1.1 Incident and Claims

The settlement concerns the incident occurring on [DATE] at [LOCATION], described as [BRIEF DESCRIPTION] (the “Incident”). Claimant asserts personal-injury and related claims arising from the Incident (the “Released Claims”).

1.2 Pending Action

• ☐ No action is pending.
• ☐ An action is pending in [COURT], County of [COUNTY], Index No. [NUMBER] (the “Action”).

1.3 Dispute and No Admission

The Settling Defendant denies liability and disputed damages. The Parties compromise disputed claims to avoid the expense, delay, and uncertainty of further proceedings. Neither this Agreement nor payment is an admission of fault or liability.

2. SETTLEMENT CONSIDERATION

2.1 Total Settlement Amount

In consideration of the Release and the other obligations in this Agreement, the Settling Defendant shall pay a total of $[TOTAL SETTLEMENT AMOUNT] (the “Settlement Amount”), allocated as follows:

2.2 No Unstated Consideration

No promise, side payment, indemnity, annuity, lien resolution, confidentiality obligation, or other consideration exists unless it is stated in this Agreement or a signed exhibit.

3. CLOSING DOCUMENTS AND PROMPT PAYMENT

3.1 Required Closing Package

Subject to Article 7, Claimant shall tender to the Settling Defendant or its designated counsel or administrator:

1. This fully executed Agreement and Release;
2. If the Action is pending, a stipulation discontinuing the Action executed on behalf of Claimant;
3. A completed Form W-9 or other tax-identification document reasonably required for payment;
4. The lien, reimbursement, escrow, or allocation documents expressly identified in Article 6; and
5. If judicial approval is required, a filed copy of the order approving the settlement and authorizing the Release, together with any other closing document required by that order.

3.2 Payment Period (select and complete one)

• ☐ Pending Action; private settling defendant — C.P.L.R. 5003-a(a). The Settling Defendant shall pay all sums due within twenty-one (21) days after Claimant's tender of the duly executed Release and the stipulation discontinuing the Action executed on Claimant's behalf.

• ☐ Pending Action; municipality or subdivision — C.P.L.R. 5003-a(b). The Settling Defendant shall pay all sums due within ninety (90) days after Claimant's tender of the duly executed Release and the stipulation discontinuing the Action executed on Claimant's behalf.

• ☐ Other legally reviewed payment provision. Payment is due [STATE THE DEADLINE AND LEGAL BASIS]. Counsel must explain why neither selection above controls.

If no Action is pending, do not use a C.P.L.R. 5003-a selection without a specific legal basis. State a definite contractual payment date in the third selection.

3.3 Tender and Proof of Receipt

For use of the C.P.L.R. 5003-a remedy, “tender” under subdivision (g) means personal delivery or mailing by registered or certified mail, return receipt requested. When mailing is used, counsel should calendar from actual receipt and preserve the signed receipt, tracking record, complete closing package, and transmittal letter.

Tender recipient: [NAME / FIRM / ADMINISTRATOR]

Tender address: [ADDRESS]

Permitted method: [PERSONAL DELIVERY / REGISTERED MAIL / CERTIFIED MAIL, RETURN RECEIPT REQUESTED]

3.4 Payment Method

Payment shall be made by [WIRE / CERTIFIED CHECK / INSURER DRAFT] according to verified instructions supplied separately. No email changing wire instructions is effective without independent verification using a previously confirmed telephone number.

3.5 No Contractual Extension of Statutory Remedy

No informal processing request, administrative delay, cure period, or force-majeure clause extends a statutory payment period unless Claimant expressly agrees in a signed writing after advice of counsel or a court orders otherwise.

4. DISCONTINUANCE OF PENDING ACTION

If the Action is pending, Claimant shall execute and tender the stipulation of discontinuance as part of the closing package required by Article 3.

The Settling Defendant or its counsel shall hold the stipulation for settlement closing and shall file or arrange filing after payment has cleared, unless applicable court procedure, an approval order, or a signed filing instruction requires another sequence.

The Parties shall not request dismissal of claims against a nonsettling party or extinguish a cross-claim, contribution claim, indemnity claim, or lienholder right unless the affected person has expressly joined in the settlement or the court has ordered that disposition.

5. RELEASE

5.1 Released Parties

“Released Parties” means the Settling Defendant and the following persons or entities, but only to the extent specifically intended and legally releasable:

[INSURER, EMPLOYEES, AGENTS, OWNERS, AFFILIATES, SUCCESSORS, OR OTHER IDENTIFIED RELEASEES].

Do not use an undefined blanket list if it could release a nonsettling tortfeasor, employer, product manufacturer, health-care provider, insurer, or other person whom Claimant does not intend to release.

5.2 Scope of Claimant's Release

In exchange for the Settlement Amount, Claimant releases the Released Parties from claims for bodily injury, pain and suffering, lost earnings, medical expenses, property damage, derivative loss, and other damages arising from the Incident through the date of this Agreement, whether known or unknown, except for:

1. Obligations created by this Agreement;
2. Claims expressly reserved in Section 5.3;
3. Rights belonging to a governmental agency, insurer, benefit plan, lienholder, or other person that has not signed a release; and
4. Any claim that applicable law or a controlling court order does not permit Claimant to release.

5.3 Expressly Reserved Claims

The following claims are not released:

[IDENTIFY ALL RESERVED CLAIMS, NONSETTLING PARTIES, UNDERINSURED-MOTORIST CLAIMS, WORKERS' COMPENSATION RIGHTS, FUTURE PAYMENT RIGHTS, OR “NONE”].

5.4 Effective Release

For a competent adult Claimant, the Release is executed and tendered as part of the settlement closing and remains subject to enforcement of the Settling Defendant's payment obligations. For an infant or incapacitated Claimant, Article 7 and the approving court order control effectiveness.

5.5 Optional Reciprocal Release

• ☐ The Settling Defendant also releases Claimant from [IDENTIFY PROPERTY-DAMAGE OR OTHER CLAIMS] arising from the Incident.
• ☐ No reciprocal release is given.

6. LIENS, REIMBURSEMENT CLAIMS, AND ALLOCATIONS

6.1 Disclosure Schedule

Claimant and counsel shall identify all known or reasonably suspected liens, reimbursement claims, benefit-plan claims, assignments, litigation-funding interests, medical-provider balances, Medicare or Medicaid interests, workers' compensation claims, and other encumbrances in Exhibit A.

6.2 Agreed Payment or Escrow

The settlement proceeds shall be handled as follows:

[STATE EACH DIRECT PAYMENT, NEGOTIATED SATISFACTION, ESCROW AMOUNT, DISPUTE PROCEDURE, AND PERSON RESPONSIBLE].

No amount may be represented as a final lien balance without current written confirmation from the holder or a legally sufficient adjudication.

6.3 Limited Allocation of Responsibility

Claimant is responsible for obligations identified in Exhibit A only to the extent stated there and permitted by law. Any indemnity must identify the particular lien or reimbursement claim, notice-and-defense procedure, control of settlement, and maximum exposure. This Agreement creates no unlimited defense-and-indemnity obligation for unknown third-party claims.

6.4 Attorney Trust Account

Counsel shall retain disputed or unresolved amounts in an attorney trust account only as required by applicable professional obligations, court order, lien law, benefit-program rules, or the written escrow terms in Exhibit A.

7. INFANT OR INCAPACITATED CLAIMANT

7.1 Applicability

• ☐ Article 7 does not apply; Claimant is a competent adult.
• ☐ Claimant is an infant.
• ☐ Claimant is a judicially declared incapacitated person or otherwise requires judicial approval.

7.2 Court Approval Is a Condition

If Article 7 applies, this Agreement and Release are subject to approval under C.P.L.R. 1207 and 1208, 22 N.Y.C.R.R. 202.67, and any other controlling law or court rule. A parent, guardian, representative, or attorney signature alone does not replace the required judicial approval.

The settlement, Release, attorney compensation, disbursements, liens, payment method, deposit or structured-payment arrangement, and distribution of net proceeds are controlled by the court's order. If this Agreement conflicts with that order, the order controls.

7.3 Current Rule 202.67 Submission Checklist

Counsel shall prepare the petition, affidavits or affirmations, exhibits, and proposed order required by the court, including as applicable:

1. Compliance with C.P.L.R. 1207 and 1208 and, for an infant, Judiciary Law § 474;
2. Itemized disbursements requested from the settlement;
3. A fee request that does not exceed one-third of the amount remaining after allowed disbursements unless the court specifically authorizes otherwise;
4. No interest charged or received by the attorney on disbursements without express approval in the court order;
5. Each doctor's and hospital's total charge and unpaid balance;
6. In-camera terms and documentation for interest or other fees charged to the claimant, contingency or deferred-payment agreements, and money borrowed against anticipated settlement proceeds, subject to the rule's attorney-financing exclusion;
7. Counsel's retainer-statement compliance and Office of Court Administration number, or an explanation why those requirements do not apply; and
8. The proposed disposition of net proceeds, including any restricted account, guardianship arrangement, bond, annuity, or structured-payment schedule required by the court.

The July 7, 2025 amendment to Rule 202.67 added the litigation-financing and related in-camera disclosure requirements summarized above. Counsel must use the rule and forms in effect when the application is filed.

7.4 Payment After Approval

After entry of the approval order, Claimant's representative shall tender the order and every closing document required by Article 3, applicable law, and the order. The payment period shall be calculated by counsel under the controlling subdivision of C.P.L.R. 5003-a.

8. OPTIONAL STRUCTURED PAYMENTS

• ☐ No structured payments are included.
• ☐ Structured payments are included under Exhibit B.

If selected, Exhibit B must state the qualified-assignment terms, assignee, annuity issuer, exact payment dates and amounts, beneficiary designation, commutation terms if any, responsibility for fees, and consequences of issuer or assignee default.

The Settling Defendant does not guarantee an assignee or annuity issuer unless Exhibit B expressly states otherwise. This Agreement makes no representation that future payment rights are transferable. Any later proposed transfer must be separately reviewed under then-current law.

For an infant or incapacitated Claimant, no structured-payment arrangement is effective unless the approving court order authorizes it on the stated terms.

9. CONFIDENTIALITY AND NON-DISPARAGEMENT OPTIONS

9.1 Confidentiality

• ☐ No confidentiality obligation is imposed.
• ☐ The Parties shall not voluntarily disclose the Settlement Amount or nonpublic settlement terms, except to attorneys, tax advisers, insurers, auditors, immediate family, lienholders, benefit programs, regulators, courts, or as required by law, subpoena, professional duty, or administration of the settlement.

9.2 Non-Disparagement

• ☐ No non-disparagement obligation is imposed.
• ☐ The following narrowly defined statement restriction applies: [TEXT].

No selected clause prohibits truthful testimony, legally required reporting, communication with government agencies, or conduct protected by controlling law.

10. NONPAYMENT AND OTHER ENFORCEMENT

10.1 C.P.L.R. 5003-a Remedy

If a Settling Defendant governed by C.P.L.R. 5003-a fails to pay within the applicable statutory period after proper tender, subdivision (e) permits an unpaid plaintiff to enter judgment without further notice for the amount stated in the Release, together with costs, lawful disbursements, and interest on that amount from the tender date.

C.P.L.R. 5003-a(e) does not itself authorize a separate attorney-fee award. This Agreement does not add prevailing-party fees to the statutory judgment remedy.

10.2 Other Material Breach

For a material breach not governed by the statutory prompt-payment remedy, the nonbreaching Party may seek relief available under the Agreement and applicable law. No remedy is exclusive unless this Agreement expressly and lawfully makes it exclusive.

10.3 No Automatic Rescission or Liability Cap

Nonpayment does not automatically rescind the settlement or revive every Released Claim; counsel must select the proper enforcement remedy. This Agreement creates no “unpaid settlement amount only” liability cap for fraud, misuse of closing documents, or another independently actionable wrong.

11. GENERAL PROVISIONS

11.1 New York Law

New York law governs this Agreement to the extent permitted by applicable choice-of-law rules.

11.2 Forum

Any enforcement application shall be made in the court retaining jurisdiction over the Action or another court with subject-matter jurisdiction and proper venue. The Parties designate [COURT AND COUNTY, IF LEGALLY REVIEWED] for a separate contract action.

11.3 No Mandatory Arbitration or Jury Waiver

This Agreement imposes no mandatory arbitration and contains no jury waiver. Any procedural right is determined by applicable law and the court in which a dispute is heard.

11.4 Entire Agreement; Amendments

This Agreement and its signed exhibits contain the complete settlement terms. An amendment or waiver must be in a signed writing, except that a court approval order controls as provided in Article 7.

11.5 Severability

If a provision is invalid or unenforceable, the remaining provisions continue to the extent they can operate consistently with the Parties' settlement and any controlling court order.

11.6 No Assignment Except Structured-Settlement Assignment

No Party may assign a claim or payment obligation under this Agreement without written consent and legal review, except for the qualified assignment expressly stated in Exhibit B.

11.7 Signatures and Copies

The Parties shall sign the same original or counterparts approved by their attorneys. Before relying on an electronic signature, scan, or copy for tender, filing, or court approval, counsel shall confirm that the recipient and court accept that format. This clause does not deem every electronic copy an original for every purpose.

11.8 No General Notary Requirement Stated

This template does not include a generic acknowledgment block. If the court, insurer, structured-settlement documents, or another closing requirement calls for notarization, counsel shall attach the correct current acknowledgment, jurat, or affidavit for that specific signer and purpose.

12. SIGNATURES

CLAIMANT

[CLAIMANT FULL LEGAL NAME]

Signature: _________________________________

Date: ______________________________________

CLAIMANT'S REPRESENTATIVE (only if applicable; subject to Article 7)

[PARENT / GUARDIAN / REPRESENTATIVE NAME AND CAPACITY]

Signature: _________________________________

Date: ______________________________________

SETTLING DEFENDANT

[SETTLING DEFENDANT NAME]

By: ________________________________________

Name and title: ____________________________

Date: ______________________________________

APPROVED AS TO FORM

Claimant's counsel: _________________________

Date: ______________________________________

Settling Defendant's counsel: _______________

Date: ______________________________________

EXHIBITS

• Exhibit A: Liens, reimbursement claims, medical balances, funding interests, and escrow terms
• Exhibit B: Structured-payment and qualified-assignment schedule (if selected)
• Exhibit C: Executed stipulation of discontinuance (if an Action is pending)
• Exhibit D: Court approval order and approved distribution schedule (if Article 7 applies)

SOURCES AND REFERENCES

• New York State Register — May 28, 2025 court notice containing the July 7, 2025 amendment to 22 N.Y.C.R.R. 202.67
• New York State Law Reporting Bureau — official 2026 decision quoting the 21-day tender and actual-receipt rule
• New York State Law Reporting Bureau — official 2025 decision quoting the 90-day municipal-payment rule
• New York State Law Reporting Bureau — official 2026 decision confirming no separate attorney-fee award under C.P.L.R. 5003-a(e)