Personal Injury Settlement Agreement - Washington

PERSONAL INJURY SETTLEMENT AGREEMENT

Washington

Before signing: If the settlement benefits an unemancipated minor or a person covered by SPR 98.16W, obtain the court's approval and follow its payment order. If other parties are involved in a pending case, complete the RCW 4.22.060 notice and reasonableness process in Section 9 with counsel.

1. Parties and incident

This Agreement is made on [__/__/____] between:

• Claimant: [FULL LEGAL NAME], of [ADDRESS]. If signing for another person, state the representative's name, capacity, and authority: [DETAILS OR "NOT APPLICABLE"].
• Settling Party: [FULL LEGAL NAME AND ENTITY TYPE, IF ANY], of [ADDRESS].
• Payor, if different: [FULL LEGAL NAME, ADDRESS, AND PAYMENT OBLIGATION OR "SAME AS SETTLING PARTY"]. A separate Payor must sign below.

Incident: [DATE, LOCATION, AND FACTS IDENTIFYING THE INJURY CLAIM].

Pending action: [COURT, CASE NUMBER, ALL PARTIES, OR "NONE"].

2. Settlement payment

Payor shall pay $[TOTAL LUMP SUM] by [METHOD] to [PAYEE] on or before [DATE OR NUMBER OF DAYS AFTER CONDITION IN SECTION 7]. Payment details and any allocation among named claimants are in the signed Schedule A.

Periodic payments: ☐ None ☐ As stated in signed Schedule B. If Schedule B is used, it must name the obligor, each amount and due date, funding instrument, and any guarantor. No party is discharged from a periodic obligation merely by purchasing an annuity or transferring a payment obligation unless the signed Schedule B expressly provides for that discharge and any required court order approves it.

3. Liens, reimbursement, fees, and net payment

Before disbursement, complete the signed Schedule A for every known or asserted medical, Medicare, Medicaid, insurer, benefit-plan, attorney, court, or other recovery claim associated with this settlement. The schedule identifies the claimant, asserted amount, dispute status, responsible person, any holdback or direct payment, and the estimated net amount to Claimant. If none are known, state "none." The parties' allocation of responsibility does not bind an unpaid third party.

For a settlement governed by SPR 98.16W, the approval petition and payment plan must disclose the connected claims, expenses, and net amount as the rule requires. Payment into the court registry or another destination follows the court's order; the structured portion is handled under the rule and order.

4. Release and reserved claims

When the lump sum has cleared and any initial funding instrument expressly required by Schedule B has been delivered, Claimant releases Settling Party and only the additional people or entities expressly named here from Claimant's claims for injury, loss, or damage arising from the incident in Section 1 through Claimant's signature date. This includes claims based on facts or the full extent of injury not now known, if they arise from that incident. The release is subject to any approval required by Section 7.

Additional persons or entities released, by full legal name and role: [LIST OR "NONE"].

Claims, benefits, or persons expressly reserved: [LIST OR "NONE"].

No claim based on conduct after Claimant's signature date, no obligation in this Agreement, and no right that cannot lawfully be released is included. Claimant signs only for Claimant or for a person whom Claimant is authorized to represent. No person not named above is released by this Agreement; RCW 4.22.060(2) governs its effect on other liable persons.

Settling Party releases Claimant from Settling Party's own claims arising from the same incident through Settling Party's signature date, except obligations created by this Agreement.

5. No admission and communications

This Agreement compromises disputed claims. Payment and signature are not admissions of liability. Either party may give truthful information to a court or government agency and comply with lawful process.

6. Pending action

If an action identified in Section 1 is pending, [RESPONSIBLE PARTY] shall submit [SPECIFIC STIPULATION OR MOTION] within [NUMBER] days after the release becomes effective and any required approval order is entered. The requested disposition is [WITH / WITHOUT] prejudice; fees and costs are allocated as stated in Schedule A. Signing this Agreement alone does not dismiss a case.

7. Court approval for affected persons

Does any part of this settlement benefit an unemancipated minor or a person covered by SPR 98.16W? ☐ No ☐ Yes.

If yes, the parties shall seek approval under SPR 98.16W before funding or disbursement inconsistent with the court's order. The petition, any Settlement Guardian ad Litem or authorized substitute report, hearing, approval order, and disposition of funds shall be handled under that rule. The settlement payment and release for the affected person are subject to the approval order.

Affected person's name and representative: [DETAILS].
Approval court, case number, and order date: [DETAILS OR "PENDING"].
Court-ordered payment destination or blocked account/trust: [DETAILS OR "PENDING"].

8. Default and changes

A payment or other promise that is not performed remains enforceable under this Agreement. The parties may seek relief available under applicable law and any applicable court order. No fixed liability cap, automatic fee award, or damages exclusion is created by this Agreement.

Washington law governs this Agreement. Changes must be in a writing signed by Claimant and Settling Party and, if the change affects Payor's duty, Payor. If a provision cannot be enforced, the remainder continues to the extent it can be carried out.

9. Other parties and reasonableness process

If an action is pending with other parties, record the RCW 4.22.060 process before signing:

10. Signatures and schedules

The following signed schedules are part of this Agreement: ☐ Schedule A (payment, liens, and net proceeds) ☐ Schedule B (periodic payments) ☐ Other [IDENTIFY] ☐ None.

Claimant or authorized representative

Signature: [________________________________]
Printed name and capacity: [________________________________]
Date: [__/__/____]

Settling Party

Signature: [________________________________]
Printed name and capacity: [________________________________]
Date: [__/__/____]

Separate Payor, if any

Signature: [________________________________]
Printed name and capacity: [________________________________]
Date: [__/__/____]

Schedule A. Payment, liens, and net proceeds

Claimant initials: [____] Settling Party initials: [____] Payor initials, if separate: [____]

Schedule B. Periodic payments (complete only if selected)

Obligor: [FULL LEGAL NAME]
Funding instrument and issuer, if any: [IDENTIFY OR "NONE"]
Guarantor, if any: [FULL LEGAL NAME OR "NONE"]
Terms of any expressly agreed discharge or substitution: [DETAILS OR "NONE"]

Claimant initials: [____] Settling Party initials: [____] Payor initials, if separate: [____]