Personal Injury Settlement Agreement - Vermont

PERSONAL INJURY SETTLEMENT AGREEMENT AND RELEASE

(Vermont)

1. Parties, Incident, and Purpose

This Personal Injury Settlement Agreement and Release (the “Agreement”) is entered into by:

• Claimant / Releasor: [FULL LEGAL NAME AND ADDRESS]
• Defendant / Releasee: [FULL LEGAL NAME, ENTITY TYPE, AND ADDRESS]
• Insurer or funding person, if a party: [NAME, CAPACITY, AND ADDRESS]

The disputed claim arises from an incident on [__/__/____] at [LOCATION] (the “Incident”). Claimant asserts injury and damages; Defendant denies liability. The Parties wish to resolve only the claims and parties identified in this Agreement, subject to the completed funding, approval, lien, and dismissal schedules.

2. Defined Settlement Scope

“Approval Order” means any court or administrative order that counsel determines is required and identifies in Exhibit D.

“Effective Date” means the last completed event selected in Section 4.

“Released Claims” means only the claims described in Exhibit A through the stated Release Date. It excludes each reserved claim, later event, and enforcement right listed there.

“Released Parties” means only the persons and entities individually named in Exhibit A. A category label must be deliberately reviewed and does not replace a complete list.

“Settlement Amount” means the total consideration stated in Section 3.

3. Settlement Funding

3.1 Total consideration: $[AMOUNT].

3.2 Funding method:

• ☐ Lump sum of $[AMOUNT] due [NUMBER] calendar days after all funding conditions occur.
• ☐ Periodic payments described completely in Exhibit B.
• ☐ Other consideration: [DESCRIPTION].

3.3 Exhibit C states every payee, amount or reserve, method, deadline, escrow condition, lien or reimbursement holdback, attorney fee and cost, and any restricted, trust, or custodial account.

3.4 No receipt is acknowledged until the promised funds or funding instruments are actually delivered.

3.5 No Party relies on this form for tax characterization, reporting, public-benefit eligibility, special-needs planning, annuity security, qualified-assignment treatment, or professional-responsibility advice. Any negotiated position must be documented in Exhibit C after advisor review.

4. Conditions and Effective Date

Select every applicable condition:

• ☐ Signature by all Parties and required representatives
• ☐ Entry of the Approval Order in Exhibit D
• ☐ Completion of the 14 V.S.A. § 2643 minor-settlement route in Section 5
• ☐ Delivery of dismissal papers to escrow
• ☐ Final Vermont Medicaid amount, agreement, determination, or holdback under Exhibit C
• ☐ Final Medicare, provider, benefit-plan, insurer, workers' compensation, child-support, attorney, or other recovery-interest process under Exhibit C
• ☐ Delivery of periodic-payment funding documents
• ☐ Other: [DESCRIPTION]

The Effective Date occurs upon: [IDENTIFY THE LAST REQUIRED EVENT].

If a required condition fails, state what happens to signatures, escrowed documents, funds, deadlines, and pending claims: [TERMS].

5. Capacity and Minor-Settlement Gate

5.1 If Claimant is an adult acting personally with legal capacity, select:

• ☐ Adult Claimant signs personally; no representative authority is asserted.

5.2 If Claimant is a minor, counsel must apply 14 V.S.A. § 2643 and complete Exhibit D:

• ☐ Claim does not exceed $10,000.00. The Superior judge of the Superior Court within and for the county where the minor resides approves and consents to the parent-executed release.
• ☐ Claim exceeds $10,000.00. A court-appointed guardian obtains the approval required by the statute and signs only within the guardian's documented authority.

Exhibit D must identify the minor's residence, settlement amount, parent or guardian, appointment, petition, review, approval, account or trust, fees and costs, distribution terms, and final order. This form does not infer that a parent alone can bind the minor or that the $10,000 threshold is a restricted-account rule.

5.3 If Claimant lacks capacity, acts through another fiduciary, represents an estate, or may require another approval, Exhibit D must identify every appointment, authority limit, required approval, and distribution restriction. No representative warrants authority beyond the attached order or instrument.

6. Dismissal and Funding Sequence

• ☐ No action is pending.
• ☐ A claimant-signed dismissal is delivered to [ESCROW / COUNSEL] and may be filed only after written confirmation that all funding conditions are satisfied.
• ☐ Funding is delivered to escrow and released only after [EVENT].
• ☐ Other sequence: [TERMS].

Any dismissal is with prejudice only as to the Released Claims against the Released Parties unless Exhibit A expressly and validly states otherwise. Litigation costs and fees are allocated as follows: [TERMS].

7. Vermont Medicaid and Other Recovery Interests

7.1 Notice and investigation. If 33 V.S.A. § 1910 applies, the recipient and the recipient's attorney must inform the Agency of Human Services in writing within a reasonable period after learning that the Agency paid medical expenses. Counsel must record the discovery steps, notice, recipients, and asserted amount in Exhibit C.

7.2 Payment or escrow. Section 1910(e)(2) requires payment to the Agency within 30 days after receipt of settlement proceeds or recovery of a judgment, or an escrow equal to the medical expenses paid pending agreement, mediation, or judicial determination. Counsel must coordinate the completed amount and allocation with controlling federal law and any Agency agreement or court determination.

7.3 Other interests. Exhibit C must separately inventory and assign responsibility for every asserted Medicare, provider, insurer, benefit-plan, workers' compensation, child-support, attorney, litigation-funding, assignment, subrogation, reimbursement, or other payment interest.

7.4 No blanket indemnity. An indemnity applies only if Exhibit C identifies the indemnifying person, protected person, specific third-party claim, notice, defense control, settlement consent, exclusions, and liability measure.

8. Release, Reserved Claims, and Other Alleged Tortfeasors

8.1 Claimant release. On the Effective Date and subject to actual funding and any required approval, Claimant releases the Released Parties from the Released Claims identified in Exhibit A.

8.2 Known and unknown claims. Select and describe the intended result:

• ☐ Only known claims listed in Exhibit A are released.
• ☐ Defined unknown consequences of the Incident are included after counsel review: [TERMS].
• ☐ The following claims, parties, benefits, liens, enforcement rights, later conduct, or time periods are reserved: [TERMS].

8.3 Defendant release:

• ☐ No reciprocal release.
• ☐ Defendant releases Claimant from only these claims: [TERMS].

8.4 Other alleged tortfeasors. Exhibit A identifies every nonsettling person against whom a claim is made and states how reserved claims, contribution, indemnity, settlement credit, allocation, and notice are treated after current Vermont-law review. This form creates no automatic release of unnamed persons.

8.5 No admission. This Agreement compromises disputed claims and is not an admission of liability.

9. Optional Conduct Terms

9.1 Confidentiality:

• ☐ None.
• ☐ Limited to: [INFORMATION / PERSONS / DURATION].

The completed clause must permit disclosures required for legal process, approval, tax or benefit reporting, lien and reimbursement resolution, insurance administration, medical care, government communications, and confidential professional advice. State the remedy, if any, only after counsel reviews proof, causation, and enforceability: [TERMS].

9.2 Non-disparagement:

• ☐ None.
• ☐ Narrow restriction: [TERMS].

The completed clause must not prohibit truthful testimony, legal process, protected government communications, medical care, insurance or benefit administration, or confidential advice.

9.3 Cooperation. Further documents may implement the completed exhibits but may not expand the Released Claims, Released Parties, or payment duties without a signed amendment and any required approval.

10. Default and Remedies

10.1 A material failure to perform an express obligation after its conditions occur is a default. A disputed lien, approval condition, or escrow instruction is not automatically a default unless this Agreement allocates that risk.

10.2 Cure:

• ☐ No contractual cure period.
• ☐ Written notice and [NUMBER] calendar days to cure, except [EXCEPTIONS].

10.3 Select negotiated remedies after counsel review:

• ☐ Action to enforce the Agreement
• ☐ Judgment for an unpaid liquidated amount
• ☐ Contract interest at [RATE] beginning [DATE], supported by [CONTRACT / AUTHORITY]
• ☐ Agreed dismissal or restoration procedure: [TERMS]
• ☐ Other: [TERMS]

10.4 Fees:

• ☐ Each Party bears its own enforcement fees and costs except as a court otherwise awards under governing law.
• ☐ Claim-specific fee provision: [TERMS AND AUTHORITY].

No automatic interest, specific performance, fee shifting, or fixed cure period is created by this form.

11. Risk Allocation

The Settlement Amount is consideration for the Released Claims, not a cap on liability for breach of this Agreement. No force-majeure term excuses funding, approval, escrow, lien, dismissal, confidentiality, or other duties unless the Parties insert a specific counsel-reviewed clause here: [TERMS].

Any indemnity must be completed only in Exhibit C as provided in Section 7.4. There is no general claimant, mutual, affiliate, successor, or insurer indemnity.

12. Governing Law and Disputes

Vermont substantive law governs this Agreement, subject to any valid choice-of-law analysis counsel records here: [TERMS].

Any filing must be made in a court with subject-matter jurisdiction and proper venue. Proposed forum: [COURT / COUNTY], subject to governing law and any Approval Order.

Select one:

• ☐ Court proceedings; no contractual arbitration requirement
• ☐ Mediation before a non-emergency enforcement filing
• ☐ Arbitration under an attached counsel-completed rider

No jury waiver is included. Any proposed waiver requires a separate, conspicuous, claim-specific provision reviewed under current Vermont law.

13. General Terms

13.1 Entire agreement. This Agreement and completed exhibits contain the settlement terms.

13.2 Amendments. An amendment or waiver must be in a record signed by every affected Party and approved through any process required by an Approval Order or governing law.

13.3 Assignment. No assignment or delegation is permitted except as expressly stated in Exhibit B or D or later approved in a signed writing.

13.4 Severability. A provision may be severed only if permitted by governing law and doing so does not materially alter the settlement exchange or release scope.

13.5 Persons bound. Only a signatory and persons or entities that signatory has authority to bind are bound. Exhibit A must identify every intended beneficiary or bound representative, heir, estate, insurer, successor, or assignee.

13.6 Counterparts and signatures. The Parties select:

• ☐ Counterpart and electronic signatures under the completed signing protocol: [TERMS].
• ☐ Wet-ink originals required for: [DOCUMENTS].

13.7 Notices. Required notices are sent by [METHOD] to [ADDRESSES] and become effective upon [DELIVERY EVENT].

14. Signatures

CLAIMANT / RELEASOR

Signature: ______________________________

Name: [NAME]

Date: [__/__/____]

Representative capacity and authority document, if any: [DETAILS]

DEFENDANT / RELEASEE

Signature: ______________________________

Name and title: [NAME / TITLE]

Date: [__/__/____]

INSURER OR OTHER REQUIRED PARTY

Signature: ______________________________

Name, capacity, and authority: [DETAILS]

Date: [__/__/____]

Use a notarial certificate only if counsel, an Approval Order, escrow, or another applicable requirement calls for one.

15. Exhibits

• Exhibit A — Released Parties, Released Claims, Reserved Claims, and Other Alleged Tortfeasors
• Exhibit B — Funding, Periodic Payments, Assignment, Annuity, and Beneficiary Terms
• Exhibit C — Payment Allocation, Fees, Costs, Vermont Medicaid, Other Recovery Interests, Holdbacks, and Any Claim-Specific Indemnity
• Exhibit D — Capacity, Fiduciary Authority, 14 V.S.A. § 2643 Approval, Restricted Funds, and Distribution Terms
• Exhibit E — Dismissal and Escrow Documents

Sources and Current-Law Notes

• 14 V.S.A. § 2643 — approval and signatory route for a parent-executed minor release at or below $10,000 and a court-appointed guardian above $10,000.
• 33 V.S.A. § 1910 — Agency notice, lien, payment, escrow, allocation, and recovery procedures when Vermont Medicaid paid medical expenses connected to the claim.