Personal Injury Settlement Agreement - Pennsylvania

PENNSYLVANIA PERSONAL-INJURY SETTLEMENT AND RELEASE

Complete every schedule before signing. Identify the actual claimant,
released parties, released claims, reserved claims, consideration, approval
path, liens, funding sequence, dismissal documents, and enforcement terms.
Do not use a generic "all claims and all parties" release when the intended
scope is narrower.

This Agreement is made as of [EFFECTIVE DATE OR SIGNATURE-SEQUENCE RULE] by
and among the persons and entities listed in Schedule A.

1. Matter and authority profile

1.1 Claimant-status screen

☐ Adult claimant acting individually

☐ Minor or person whose capacity requires separate review

☐ Decedent's estate or personal representative

☐ Wrongful-death beneficiaries or representative

☐ Guardian, conservator, parent, fiduciary, trustee, or other representative

☐ Bankruptcy debtor, estate, or trustee interest

☐ Multiple claimants, derivative claimants, or consortium claim

☐ Government, benefit-plan, workers' compensation, provider, attorney, or
other asserted reimbursement or lien interest

☐ Other status: [________________________________]

1.2 Current-law and approval register

2. Recitals and disputed matter

A. On or about [DATE], [DESCRIBE INCIDENT WITHOUT ADMITTING A DISPUTED FACT].

B. [CLAIMANT] asserts [IDENTIFY CLAIMS AND INJURIES].

C. [DEFENDANT / SETTLING PARTY] denies [LIABILITY / DAMAGES / COVERAGE / OTHER]
except as expressly stated here: [________________________________].

D. The Parties wish to resolve only the claims and interests identified in
Schedule B, without an admission except as expressly stated.

The recitals are:

☐ contractual statements forming part of the Agreement

☐ background only and not independent representations

3. Settlement consideration and funding

3.1 Monetary consideration

The Settling Party will pay $[AMOUNT] as follows:

3.2 Nonmonetary consideration

[IDENTIFY PROPERTY, CORRECTION, CONFIDENTIALITY, REFERENCE, SERVICE, DISMISSAL,
APOLOGY, POLICY TERM, OR OTHER CONSIDERATION, OR STATE "NONE." ]

3.3 Funding sequence

Select and complete the actual sequence:

☐ signatures before funding

☐ required approval or order before funding

☐ funds deposited in escrow pending approval

☐ lien or reimbursement holdback pending final resolution

☐ release delivered before funding

☐ release effective only after cleared funds

☐ dismissal or discontinuance held and filed after cleared funds

☐ structured or periodic payment documents completed before effectiveness

☐ other sequence: [________________________________]

Escrow holder, instructions, interest treatment, return conditions, and
dispute procedure: [________________________________]

3.4 Structured or periodic payment — only if selected

No tax, qualified-assignment, annuity, transfer, or security result is stated
unless the completed documents and authority register support it.

4. Released and reserved matters

4.1 Released claims

Upon [CLEARED PAYMENT / APPROVAL / OTHER EFFECTIVE TRIGGER], each Releasing
Person releases only the claims described in Schedule B against only the
Released Persons identified there, for the stated time period and incident.

4.2 Reserved claims and persons

The following are not released: [IDENTIFY CLAIMS, LIENS, BENEFITS, FUTURE
OBLIGATIONS, CONTRACT RIGHTS, ENFORCEMENT RIGHTS, PERSONS, OR STATE "NONE"].

4.3 Scope choices

No signer purports to release a claim owned by another person unless that
authority is documented in Schedule A.

5. Dismissal and litigation documents

Each Party bears these litigation costs and fees unless Schedule C states
otherwise: [________________________________].

6. Liens, reimbursement, and third-party interests

The Parties select this treatment after counsel review:

☐ direct payment to identified holder

☐ escrow or holdback pending final amount

☐ claimant responsibility without indemnity

☐ specifically negotiated indemnity limited to: [________________________________]

☐ defense and settlement-control procedure: [________________________________]

☐ other: [________________________________]

Do not state that the settlement "fully satisfies" an unknown or unresolved
interest. Attach final notices, waivers, agreements, or orders when available.

7. Representations and acknowledgments

Each Party makes only the representations selected below:

☐ identity and authority to sign

☐ no identified prior assignment except as listed in Schedule A

☐ opportunity to consult independent legal and tax advisers

☐ review and understanding of the final Agreement and exhibits

☐ factual disclosure identified here: [________________________________]

☐ no additional representation

No representation survives closing unless Schedule C identifies the speaker,
subject, duration, materiality standard, knowledge qualifier, and remedy.

8. Confidentiality, disclosure, and communications — optional

☐ No confidentiality obligation.

☐ The following information is confidential: [________________________________].

Permitted disclosures: [LEGAL / TAX / FINANCIAL ADVISERS, INSURERS, AUDITORS,
COURTS, GOVERNMENT, LIEN HOLDERS, IMMEDIATE FAMILY, REQUIRED REPORTS, OR OTHER].

Required-process and truthful-testimony treatment: [________________________________].

Confidentiality duration, notice, cure, proof, and remedies: [________________________________].

Non-disparagement, if separately negotiated, must identify the speakers,
communications, audience, duration, exceptions, and remedies: [________________________________].

9. Tax, benefits, and reporting

No Party gives tax or benefits advice through this form. An allocation binds
only to the extent governing law and the actual facts give it effect.

10. Breach and enforcement terms

No automatic fee award, interest rate, cure period, specific performance,
injunction, liability cap, force-majeure excuse, arbitration, forum, or jury
term applies unless completed here after counsel review.

11. General terms

12. Signatures

Each signer represents only that the signer has the authority documented in
Schedule A and intends to agree to the completed terms and attached schedules.

Additional required signer, fiduciary, insurer, lien holder, or approving
person: [________________________________]

Notarization or verification requirement and authority: [________________________________]

SCHEDULE A — PARTIES, CAPACITY, AND AUTHORITY

SCHEDULE B — RELEASE MATRIX

SCHEDULE C — PAYMENT, APPROVAL, LIEN, AND ENFORCEMENT TERMS

Attach the completed payment table, approval documents, distribution plan,
lien schedule, dismissal documents, confidentiality selection, surviving
representations, and enforcement terms.

FINAL REVIEW

☐ Every claimant, released person, claim, reserved claim, and capacity identified

☐ Current authority and approval register completed from permitted official sources

☐ Consideration, escrow, approval, funding, release, and dismissal sequence reconciled

☐ Liens, reimbursement claims, fees, costs, taxes, benefits, and reporting reviewed

☐ Optional confidentiality, indemnity, remedies, and dispute terms completed or deleted

☐ Every exhibit, order, release, petition, dismissal, and signature document attached

☐ Qualified Pennsylvania counsel approved the final agreement

This template is provided for informational purposes only and does not
constitute legal advice.