PERSONAL INJURY SETTLEMENT AGREEMENT

(Washington State)

[// GUIDANCE: Insert all bracketed placeholders before circulation. Consider deleting inapplicable optional sections (e.g., “Minor Settlement Approval”) if the facts do not require them.]

TABLE OF CONTENTS

1. Document Header.....................................................................................................................1
2. Definitions..............................................................................................................................2
3. Operative Provisions............................................................................................................4
4. Representations & Warranties..........................................................................................7
5. Covenants & Restrictions.................................................................................................8
6. Default; Remedies.............................................................................................................9
7. Risk Allocation..................................................................................................................10
8. Dispute Resolution...........................................................................................................11
9. General Provisions...........................................................................................................12
10. Execution Block..............................................................................................................14

Page numbers adjust automatically in word-processing applications.

1. DOCUMENT HEADER

This Personal Injury Settlement Agreement and Mutual Release (this “Agreement”) is made and entered into as of [EFFECTIVE DATE] (the “Effective Date”) by and among:

(a) [INJURED PARTY LEGAL NAME], [individual/an entity], [social security number or EIN redacted for privacy] (“Releasor”);

(b) [DEFENDANT LEGAL NAME], a [STATE] [corporation/LLC/individual], including its past, present, and future parents, subsidiaries, affiliates, officers, directors, shareholders, owners, insurers, reinsurers, employees, agents, attorneys, representatives, predecessors, successors, and assigns (collectively, “Released Parties”); and

(c) [INSURANCE CARRIER], as applicable.

The above may each be referred to as a “Party” and collectively as the “Parties.”

Recitals

A. On or about [DATE OF INCIDENT] an occurrence at or near [LOCATION] (the “Incident”) allegedly caused personal injuries and other damages to Releasor (the “Claims”).

B. The Parties desire to fully, finally, and forever compromise and settle all Claims upon the terms set forth herein, without admission of liability.

C. Adequate and independent consideration exists for the promises and releases herein.

NOW, THEREFORE, in consideration of the mutual covenants and agreements set forth below, and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Parties agree as follows:

2. DEFINITIONS

For purposes of this Agreement, capitalized terms have the meanings set forth below; terms defined herein include the plural as well as the singular and vice versa.

“Agreement” – This Personal Injury Settlement Agreement and Mutual Release, including all exhibits, schedules, and written amendments.

“Annuity Provider” – [NAME OF QUALIFIED ASSIGNMENT COMPANY/INSURER] issuing the structured settlement annuity, if any.

“Claims” – Any and all past, present, or future claims, causes of action, demands, damages, costs, expenses, liens, set-offs, defenses, losses, rights, and liabilities of any nature whatsoever, whether known or unknown, suspected or unsuspected, fixed or contingent, in law or equity, arising from or relating to the Incident.

“Court” – The Superior Court of the State of Washington for [COUNTY], or such other court of competent jurisdiction as may be required.

“Effective Date” – The date first written above, subject to Section 3.9 (Court Approval Condition) if applicable.

“Guardian Ad Litem” – A guardian ad litem or other fiduciary appointed by a Washington State court to act on behalf of a Minor with respect to this Agreement.

“Medicare” – The federal health insurance program under Title XVIII of the Social Security Act.

“Minor” – Any person who has not yet attained eighteen (18) years of age and on whose behalf any portion of this settlement is made.

“Payor” – Released Parties responsible for funding the Settlement Amount.

“Periodic Payments” – Payments made pursuant to the Structured Settlement described in Section 3.3.

“Releasor” – The person(s) identified in the Document Header executing this Agreement as claimant/plaintiff.

“Released Parties” – Defined in Document Header subsection (b) above.

“Settlement Amount” – The total consideration to be paid in exchange for the releases herein, consisting of any Lump-Sum Payment and/or Periodic Payments as set forth in Section 3.2 and Section 3.3.

“Structured Settlement” – A settlement funded in whole or in part by Periodic Payments pursuant to a qualified assignment under 26 U.S.C. § 130.

3. OPERATIVE PROVISIONS

3.1 Settlement Obligation. Subject to the terms and conditions herein, Payor shall pay, or cause to be paid, the Settlement Amount to Releasor as set forth below in full satisfaction of all Claims.

3.2 Lump-Sum Payment.
(a) Amount: $[LUMP-SUM AMOUNT].
(b) Timing: Within [NUMBER] calendar days after the later of (i) Payor’s receipt of this Agreement duly executed by all Parties, and (ii) satisfaction or waiver of all conditions precedent set forth in Section 3.9.
(c) Method: [Wire transfer/check] payable to “[LAW FIRM IOLTA]/[RELEASOR NAME]”.

3.3 Structured Settlement (Optional).
(a) Periodic Payment Schedule: As detailed in Exhibit A.
(b) Qualified Assignment. Payor may effect a qualified assignment to Annuity Provider pursuant to 26 U.S.C. § 130, after which Payor shall have no further liability for the Periodic Payments.
(c) Security. Periodic Payments shall be secured solely by the annuity contract issued by Annuity Provider; Releasor shall have no recourse against Payor for Annuity Provider’s failure.

[// GUIDANCE: Delete Section 3.3 if the settlement is lump-sum only.]

3.4 Liens & Subrogation. Releasor shall satisfy and resolve all valid medical, government, attorney, and third-party liens (including Medicare conditional payments) arising from the Incident. Releasor shall indemnify Released Parties against any failure to satisfy such liens (see Section 7.2).

3.5 Tax Treatment. The Parties intend that amounts paid on account of personal physical injuries or physical sickness are excludable from gross income under 26 U.S.C. § 104(a)(2). Each Party shall be solely responsible for its own tax reporting and liabilities.

3.6 No Admission. This Agreement constitutes a compromise of disputed claims and shall not be construed as an admission of liability by any Party.

3.7 Confidentiality. Except as required by law, court order, lien resolution, or for tax/financial reporting, the Parties shall keep the terms of this Agreement confidential.

[// GUIDANCE: Consider Washington’s public-policy limits on confidentiality where minors are involved.]

3.8 Mutual Release. Subject to receipt of the Settlement Amount, Releasor irrevocably releases and forever discharges Released Parties from all Claims. Released Parties likewise release Releasor solely for any claims arising out of the Incident. This mutual release includes unknown or unsuspected Claims, and Releasor expressly waives all rights under any law intended to limit such releases.

3.9 Conditions Precedent. The following are express conditions precedent to Payor’s funding obligation:
(i) Receipt of all required signatures;
(ii) Delivery of completed IRS Form W-9 (if an individual) or W-8 (if applicable);
(iii) Court approval pursuant to Section 3.10 if a Minor or incapacitated person is involved; and
(iv) Execution of all exhibits (e.g., Assignment Agreement, Medicare addendum).

3.10 Minor Settlement Approval (If Applicable).
(a) Petition. Where Releasor is a Minor, a Petition for Approval of Settlement shall be filed with the Court pursuant to applicable Washington procedural rules.
(b) Guardian Ad Litem. A Guardian Ad Litem shall be appointed to evaluate and recommend the settlement’s adequacy.
(c) Funding. Payor shall not fund any portion of the Settlement Amount until entry of a final order approving the settlement and authorizing disbursement according to Section 3.2 and/or Section 3.3.
(d) Deposit/Blocked Account. Lump-sum proceeds attributable to a Minor shall be deposited into a blocked account or trust as directed by the Court.

[// GUIDANCE: SPR 98 and RCW 4.08 et seq. require court approval for minor settlements in WA.]

4. REPRESENTATIONS & WARRANTIES

4.1 Releasor. Releasor represents and warrants that:
(a) Releasor is the sole person/entity entitled to assert the Claims and has not assigned or transferred any interest therein;
(b) Releasor has the legal capacity and authority to enter into this Agreement (or, where a Minor or incapacitated adult, acts through a court-appointed Guardian Ad Litem or conservator);
(c) Releasor has obtained (or will obtain) independent legal advice concerning this Agreement; and
(d) Execution of this Agreement does not violate any other agreement or court order.

4.2 Released Parties. Each Released Party represents and warrants that it has authority to enter into and perform this Agreement and, if an entity, that execution is duly authorized by all necessary corporate or company action.

4.3 Survival. The representations and warranties in this Article 4 shall survive the Effective Date and the delivery of the Settlement Amount.

5. COVENANTS & RESTRICTIONS

5.1 No Further Litigation. Releasor covenants that he/she/it will not institute or maintain any civil, administrative, or other action based on Claims released herein.

5.2 Dismissal With Prejudice. Within three (3) business days after Payor funds the Lump-Sum Payment, the Parties shall file a stipulated dismissal with prejudice (and without costs) in any pending litigation arising from the Incident.

5.3 Non-Disparagement. The Parties shall refrain from making public statements, oral or written, that are materially disparaging of another Party concerning the Incident or this Agreement.

5.4 Cooperation. The Parties shall cooperate reasonably to effect lien resolution, Medicare compliance, and (if applicable) court approval.

6. DEFAULT & REMEDIES

6.1 Events of Default.
(a) Payor Default: Failure to timely fund any portion of the Settlement Amount.
(b) Releasor Default: Breach of the confidentiality or non-disparagement covenants; institution of a barred claim; or failure to obtain lien satisfaction.

6.2 Notice & Cure. The non-defaulting Party shall provide written notice specifying the nature of the default. The defaulting Party shall have ten (10) calendar days to cure after receipt.

6.3 Remedies. If the default is not cured:
(a) Payor Default: Releasor may enforce payment plus interest at [STATE JUDGMENT RATE] from the original due date, and may obtain judgment in the Settlement Amount less any funds previously paid;
(b) Releasor Default: Released Parties may seek reimbursement of amounts paid, specific performance, and reasonable attorney fees incurred in enforcement.

6.4 Limitations. In no event shall either Party be liable for consequential, incidental, punitive, or special damages except as expressly provided in this Agreement.

7. RISK ALLOCATION

7.1 Mutual Release. See Section 3.8 (incorporated herein by reference).

7.2 Indemnification.
(a) Releasor shall indemnify, defend, and hold harmless Released Parties from any claims or liens asserted by healthcare providers, governmental agencies (including CMS), insurers, or other third parties arising from the Incident or Settlement Amount.
(b) Released Parties shall indemnify Releasor for claims arising solely from Released Parties’ breach of this Agreement.

7.3 Limitation of Liability. The maximum aggregate liability of Released Parties under or in connection with this Agreement shall not exceed the Settlement Amount.

7.4 Force Majeure. No Party shall be liable for failure or delay in performance caused by events beyond its reasonable control (including natural disasters, war, acts of terrorism, or government action) provided that such Party gives prompt notice and resumes performance as soon as practicable.

8. DISPUTE RESOLUTION

8.1 Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the State of Washington, without regard to conflict-of-laws principles.

8.2 Venue. The Parties consent to exclusive jurisdiction and venue in the Superior Court of the State of Washington for [COUNTY] for any dispute arising under this Agreement.

8.3 Arbitration. Not applicable (intentionally omitted).

8.4 Jury Waiver. Not applicable (intentionally omitted).

8.5 Attorney Fees. In any proceeding to enforce this Agreement, the prevailing Party shall be entitled to recover reasonable attorney fees, costs, and expenses.

9. GENERAL PROVISIONS

9.1 Entire Agreement. This Agreement constitutes the complete and exclusive statement of the agreement between the Parties and supersedes all prior or contemporaneous oral or written understandings.

9.2 Amendment & Waiver. No amendment or waiver of any provision shall be effective unless in writing and signed by all Parties. Waiver of any breach shall not operate as a waiver of any subsequent breach.

9.3 Severability. If any provision is held invalid or unenforceable, the remaining provisions shall continue in full force, and the invalid provision shall be reformed to the minimum extent necessary to effectuate the Parties’ intent.

9.4 Assignment. Releasor may not assign any rights or delegate any obligations under this Agreement without prior written consent of Payor, except that rights to receive Periodic Payments may be assigned only in compliance with applicable structured-settlement protection statutes and court approval. Released Parties may assign obligations to an Annuity Provider pursuant to Section 3.3.

9.5 Successors & Assigns. This Agreement is binding on and inures to the benefit of the Parties and their respective heirs, executors, administrators, successors, and permitted assigns.

9.6 Counterparts; Electronic Signatures. This Agreement may be executed in counterparts (including by facsimile or PDF), each of which is deemed an original, and all of which together constitute one instrument. Electronic signatures shall be deemed original and enforceable.

9.7 Headings. Headings and titles are for convenience only and shall not affect interpretation.

9.8 Construction. The Parties acknowledge that they have been represented by counsel and that this Agreement shall not be construed against any Party as drafter.

10. EXECUTION BLOCK

IN WITNESS WHEREOF, the Parties have executed this Personal Injury Settlement Agreement and Mutual Release as of the Effective Date.

[// GUIDANCE: Adjust signature blocks to match party status; include notary if desired for recordability.]

RELEASOR

[PRINT NAME]
Date: ___

If Minor/Incapacitated:

[PRINT NAME], as court-appointed Guardian Ad Litem for [MINOR NAME]
Date: ___

PAYOR / RELEASED PARTY

[AUTHORIZED SIGNATORY, TITLE]
[ENTITY NAME]
Date: ___

INSURER (If Separate Signatory)

[AUTHORIZED SIGNATORY, TITLE]
[INSURANCE COMPANY NAME]
Date: ___

NOTARY ACKNOWLEDGMENT (Optional)

State of Washington )
County of _____ ) ss.

On this _ day of _, 20__, before me, the undersigned Notary Public, personally appeared ______, proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to this instrument, and acknowledged that he/she/they executed the same for the purposes therein contained.

IN WITNESS WHEREOF I hereunto set my hand and official seal.

Notary Public for the State of Washington
My Commission Expires: ______

EXHIBIT A – PERIODIC PAYMENT SCHEDULE

[// GUIDANCE: List payment dates, amounts, life-contingent terms, annuity issuer details, and qualified assignment language.]

EXHIBIT B – MEDICARE SECONDARY PAYER ADDENDUM

[// GUIDANCE: Insert conditional payment resolution details, Medicare Set-Aside (if any), and mutual cooperation obligations.]

End of Document