PERSONAL INJURY SETTLEMENT AGREEMENT

AND MUTUAL RELEASE

(State of Wisconsin)

[// GUIDANCE: Insert matter caption or reference court case number here if the claim is in suit.]

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

1. [CLAIMANT FULL LEGAL NAME], an individual with an address at [CLAIMANT ADDRESS] (“Claimant”); and
2. [DEFENDANT FULL LEGAL NAME], a [legal entity type & state of organization] with its principal place of business at [DEFENDANT ADDRESS] (“Defendant”).

Claimant and Defendant are sometimes referred to in this Agreement individually as a “Party” and collectively as the “Parties.”

TABLE OF CONTENTS

I. Document Header
II. Definitions
III. Operative Provisions
IV. Representations & Warranties
V. Covenants & Restrictions
VI. Default & Remedies
VII. Risk Allocation
VIII. Dispute Resolution
IX. General Provisions
X. Execution Block

I. DOCUMENT HEADER

1.1 Recitals

A. A dispute has arisen out of an incident that occurred on or about [DATE OF INCIDENT] in [LOCATION], resulting in alleged bodily injury to Claimant (the “Incident”).
B. Claimant contends that Defendant is legally responsible for the injuries and damages arising from the Incident (the “Claims”).
C. Defendant denies all liability but desires to compromise, settle, and fully resolve the Claims to avoid the expense and uncertainty of litigation.
D. The Parties wish to memorialize their settlement and mutual release of all Claims under the terms and conditions set forth herein.

1.2 Consideration

The mutual promises and payments described in Section III constitute good and valuable consideration, the receipt and sufficiency of which each Party acknowledges.

1.3 Governing Law and Jurisdiction

This Agreement is governed by the substantive tort and contract laws of the State of Wisconsin without regard to its conflict-of-laws rules. Exclusive venue lies in the state courts of [COUNTY], Wisconsin.

II. DEFINITIONS

The following terms have the meanings set forth below. Capitalized terms used in the singular include the plural and vice-versa.

“Agreement” has the meaning set forth in the preamble.
“Claims” means any and all past, present, or future claims, demands, causes of action, liabilities, liens, rights, damages, costs, or expenses of whatever kind or nature, whether known or unknown, that arise out of or relate to the Incident.
“Confidential Information” has the meaning provided in Section V.2.
“Defendant” has the meaning set forth in the preamble.
“Effective Date” has the meaning set forth in the preamble.
“Incident” has the meaning set forth in Recital A.
“Medicare Secondary Payer Statute” means 42 U.S.C. § 1395y(b) and its implementing regulations.
“Minor” means an individual who has not reached the age of majority under Wis. Stat. § 990.01(20).
“Party” and “Parties” have the meanings set forth in the preamble.
“Settlement Amount” has the meaning set forth in Section III.1.

[// GUIDANCE: Add additional defined terms as needed for structured settlements, guardians, etc.]

III. OPERATIVE PROVISIONS

3.1 Settlement Payment

(a) Defendant shall pay Claimant the total sum of [USD $__] (the “Settlement Amount”), allocated as set forth below, within [___] business days after (i) full execution of this Agreement and (ii) receipt of all court approvals required under Section 3.4 (if applicable).
(b) Delivery. Payment shall be made by [certified check/wire transfer] to [Payee/Trust Account].
(c) Structured Settlement (Optional). If the Parties elect a periodic payment structure:

i. A qualified assignment shall be executed consistent with 26 U.S.C. § 130 and 26 U.S.C. § 104(a)(2).
ii. Exhibit A shall set forth the payment schedule, annuity issuer, and assignment terms.

[// GUIDANCE: Delete subsection (c) if a lump-sum settlement is agreed.]

3.2 Release of Claims

Upon Defendant’s timely payment of the Settlement Amount, Claimant irrevocably and unconditionally releases and forever discharges Defendant, its past, present, and future parents, subsidiaries, affiliates, insurers, reinsurers, successors, and assigns from any and all Claims.

3.3 Mutual Release

Defendant, for itself and the other Released Parties, releases Claimant from all claims arising out of or relating to the Incident, except for obligations created by this Agreement.

3.4 Minor Settlement Approval (If Applicable)

(a) If Claimant is a Minor or asserts claims on behalf of a Minor, the settlement is contingent upon entry of an order approving the compromise pursuant to Wis. Stat. § 807.10.
(b) The Parties shall promptly submit a joint petition for approval in the [appropriate circuit] court.
(c) Any required guardianship or conservatorship shall be established prior to disbursement.

3.5 Liens and Subrogation Interests

Claimant shall satisfy or compromise all valid medical liens, subrogation interests, and Medicare conditional payments arising from the Incident. Claimant shall indemnify Defendant against any lienholder or governmental recovery action, subject to Section VII.

IV. REPRESENTATIONS & WARRANTIES

Each Party represents and warrants to the other that:

4.1 Authority. It has full legal right, power, and authority to execute and perform this Agreement. If acting through a representative, such representative has been duly appointed and authorized.

4.2 No Assignment. It has not assigned or transferred any Claim or right released herein.

4.3 Independent Counsel. It has had the opportunity to consult independent legal counsel and freely enters into this Agreement.

4.4 No Reliance. It is not relying on any statement or representation by any other Party except as expressly set forth in this Agreement.

4.5 Tax Advice Disclaimer. It has received or waived independent tax advice regarding the Settlement Amount.

4.6 Survival. The representations and warranties in this Article IV survive the Effective Date.

V. COVENANTS & RESTRICTIONS

5.1 Dismissal of Litigation. Within [___] days after receipt of the Settlement Amount, the Parties shall file a stipulation dismissing with prejudice any lawsuit relating to the Incident, each Party to bear its own costs and fees.

5.2 Confidentiality. Except as required by law or court order, the Parties shall keep the terms of this Agreement and all settlement communications strictly confidential (“Confidential Information”) and shall not disclose them to any third party other than: (i) attorneys, accountants, insurers, or tax advisors with a need to know; (ii) taxing authorities; or (iii) as necessary to enforce this Agreement.

5.3 Non-Disparagement. The Parties shall not make statements, written or oral, that disparage or defame the other concerning the Incident or this settlement.

5.4 Cooperation. The Parties shall execute all documents and take any additional actions reasonably necessary to effectuate this Agreement.

5.5 Medicare Compliance. Claimant shall comply with the Medicare Secondary Payer Statute and shall provide Defendant written confirmation of final conditional payment resolution.

VI. DEFAULT & REMEDIES

6.1 Events of Default
(a) Failure by Defendant to pay the Settlement Amount in full when due.
(b) Breach of confidentiality or non-disparagement obligations.
(c) Failure by Claimant to obtain required court approval under Section 3.4.

6.2 Notice and Cure
A Party alleging default shall provide written notice describing the default in reasonable detail. The breaching Party has [10] business days after receipt to cure, except that payment defaults must be cured within [5] business days.

6.3 Remedies
(a) If Defendant defaults on payment and fails to cure, Claimant may: (i) enter judgment for the unpaid Settlement Amount plus interest at the statutory rate; and/or (ii) reinstate any dismissed action arising from the Incident.
(b) If Claimant breaches confidentiality or non-disparagement, Defendant may seek equitable relief, including temporary or permanent injunction, and liquidated damages of [USD $_____] per breach, which the Parties stipulate is a reasonable pre-estimate of damages.

6.4 Attorneys’ Fees
The prevailing Party in any action to enforce this Agreement is entitled to recover its reasonable attorneys’ fees and costs.

VII. RISK ALLOCATION

7.1 Mutual Indemnification & Hold Harmless
(a) Claimant shall indemnify, defend, and hold harmless Defendant from any lien, subrogation claim, or governmental reimbursement demand relating to medical expenses or benefits paid on Claimant’s behalf arising from the Incident.
(b) Defendant shall indemnify, defend, and hold harmless Claimant from any claim brought by third parties asserting derivative liability against Claimant arising solely from Defendant’s acts or omissions unrelated to the Incident.

7.2 Limitation of Liability
Except for a Party’s indemnification obligations, breach of confidentiality, or fraud, each Party’s aggregate liability under this Agreement is capped at the Settlement Amount actually received or payable.

7.3 Force Majeure
Neither Party is liable for failure to perform due to events beyond its reasonable control, including acts of God, war, terrorism, or governmental action, provided the affected Party gives prompt notice and uses diligent efforts to resume performance.

VIII. DISPUTE RESOLUTION

8.1 Governing Law
This Agreement and any dispute hereunder are governed by Wisconsin law.

8.2 Forum Selection
Any suit, action, or proceeding arising out of or relating to this Agreement shall be instituted exclusively in the state courts of [COUNTY], Wisconsin, and the Parties irrevocably submit to such jurisdiction.

8.3 Jury Trial
Each Party acknowledges that a jury waiver is not applicable under the Parties’ metadata selection; accordingly, the Parties retain the right to a jury trial consistent with Wisconsin law.

8.4 Equitable Relief
Nothing in this Article VIII restricts either Party from seeking interim or permanent injunctive relief for breach of confidentiality, non-disparagement, or indemnification obligations.

IX. GENERAL PROVISIONS

9.1 Entire Agreement
This Agreement constitutes the entire agreement between the Parties with respect to the subject matter and supersedes all prior negotiations and agreements.

9.2 Amendment and Waiver
No amendment or waiver is effective unless in writing and signed by all Parties. A waiver on one occasion is not a waiver on any subsequent occasion.

9.3 Assignment
No Party may assign its rights or delegate its duties without the prior written consent of the other Party, except that Defendant may assign to its insurer or an annuity issuer for purposes of a structured settlement.

9.4 Severability
If any provision is held invalid or unenforceable, the remaining provisions remain in full force, and the invalid provision will be reformed to the minimum extent necessary to render it valid.

9.5 Successors and Assigns
This Agreement binds and benefits the Parties and their respective heirs, personal representatives, successors, and permitted assigns.

9.6 Counterparts; Electronic Signatures
This Agreement may be executed in counterparts, each of which is deemed an original, and all of which together constitute one instrument. Signatures transmitted by facsimile, PDF, or DocuSign (or similar) are deemed originals.

9.7 Headings
Headings are for convenience only and do not affect interpretation.

9.8 Construction
The Parties have jointly participated in drafting; no presumption against a drafter shall apply.

X. EXECUTION BLOCK

IN WITNESS WHEREOF, the Parties have executed this Agreement as of the Effective Date.

[// GUIDANCE: If Claimant is a Minor, add signature blocks for parent/guardian and court approval lines.]

NOTARIZATION (Optional if required)

State of Wisconsin
County of _______

Subscribed and sworn before me on ___, 20_, by ______.

Notary Public
My commission expires: _______

EXHIBIT A

(Structured Settlement Payment Schedule)

[// GUIDANCE: Attach annuity terms, payment amounts, due dates, qualified assignment language, and issuer information.]

[// GUIDANCE: Prior to use, counsel should:
1. Confirm lien resolution amounts and attach proof as an exhibit;
2. Verify compliance with Wis. Stat. § 807.10 for minor settlements;
3. Tailor confidentiality carve-outs for regulatory reporting;
4. Review Medicare Set-Aside requirements, if any;
5. Replace all bracketed placeholders and remove guidance comments before execution.]