PERSONAL INJURY SETTLEMENT AGREEMENT
AND MUTUAL RELEASE
State of Wyoming
[// GUIDANCE: This template is drafted for use in Wyoming personal-injury matters. Edit bracketed text, delete inapplicable provisions, and circulate for full legal review before execution.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Effective Date. This Personal Injury Settlement Agreement and Mutual Release (“Agreement”) is made and entered into as of [EFFECTIVE DATE] (the “Effective Date”).
1.2 Parties.
(a) Claimant: [CLAIMANT LEGAL NAME], [individual / corporate form], with an address at [ADDRESS] (“Claimant”).
(b) Released Parties: [DEFENDANT LEGAL NAME], together with its present and former parents, subsidiaries, affiliates, insurers, reinsurers, principals, officers, directors, shareholders, employees, agents, representatives, predecessors, successors, and assigns (collectively, “Released Parties”).
1.3 Recitals.
A. On or about [DATE OF INCIDENT], Claimant sustained alleged bodily injuries and other damages in [LOCATION] (the “Incident”).
B. Claimant contends that Released Parties are legally responsible for the Incident and has asserted claims for personal injury and related damages (the “Claims”).
C. Released Parties deny any liability but, in order to avoid the uncertainty and expense of litigation, desire to compromise and settle all Claims on the terms set forth below.
D. The Parties enter into this Agreement in exchange for good and valuable consideration, the receipt and sufficiency of which are acknowledged.
NOW, THEREFORE, in consideration of the mutual covenants and promises herein, and intending to be legally bound, the Parties agree as follows:
2. DEFINITIONS
The following capitalized terms shall have the meanings set forth below. Terms defined in the singular have the same meaning in the plural and vice versa.
“Agreement” has the meaning set forth in Section 1.1.
“Claim(s)” means any and all past, present, or future demands, actions, causes of action, suits, liabilities, rights, debts, dues, sums of money, accounts, reckonings, bonds, bills, covenants, contracts, controversies, agreements, promises, damages, judgments, executions, claims, and demands of whatsoever kind or nature, whether known or unknown, foreseen or unforeseen, in law or equity, arising out of or relating to the Incident.
“Final Approval” means, if required under Section 3.6 (Minor or Incompetent Claimant), the date on which the appropriate Wyoming state district court enters a final, non-appealable order approving this settlement.
“Medicare Secondary Payer Laws” means 42 U.S.C. § 1395y(b) and related regulations and guidance.
“Net Settlement Proceeds” means the Settlement Amount less any court-approved attorney fees, costs, medical liens, subrogation interests, and other deductions authorized herein.
“Settlement Amount” has the meaning set forth in Section 3.1.
“Structured Settlement” has the meaning set forth in Section 3.2.
3. OPERATIVE PROVISIONS
3.1 Settlement Consideration.
(a) Monetary Payment. Released Parties shall pay or cause to be paid to Claimant the total sum of [SETTLEMENT AMOUNT IN WORDS] ([USD $__]) (the “Settlement Amount”) in accordance with Section 3.3.
(b) Sole Consideration. The Settlement Amount constitutes the sole and exclusive consideration for the releases, covenants, and agreements herein.
3.2 Structured Settlement (if elected).
(a) Form. All or part of the Settlement Amount may be funded through an agreed structured settlement annuity (the “Structured Settlement”) providing the periodic payments set forth in Exhibit A.
(b) Compliance. Any Structured Settlement shall comply with:
i. Section 104(a)(2) and Section 130 of the Internal Revenue Code; and
ii. The Wyoming Structured Settlement Protection Act, [insert statutory citation if known with certainty].
(c) Qualified Assignment. Claimant consents to the assignment of Released Parties’ periodic-payment obligations to a qualified assignee pursuant to 26 U.S.C. § 130(c).
[// GUIDANCE: Delete Section 3.2 if entire Settlement Amount will be paid in a single lump sum.]
3.3 Funding and Delivery.
(a) Timing. Released Parties shall remit the lump-sum portion of the Settlement Amount within [___] business days after satisfaction of all Conditions Precedent in Section 3.5.
(b) Method. Payment shall be made by wire transfer or trust account check payable to [PAYEE], to be deposited into the trust account of Claimant’s counsel, [LAW FIRM NAME], IOLTA Account No. [___].
3.4 Liens and Subrogation Interests.
Claimant shall be solely responsible for negotiating, satisfying, and discharging all hospital, medical, governmental (including Medicare, Medicaid, TRICARE, and VA), workers’ compensation, and other liens or subrogation interests arising from the Incident. Claimant agrees to indemnify and hold harmless Released Parties from any failure to satisfy such obligations as provided in Section 7.2.
3.5 Conditions Precedent.
The obligations of Released Parties to fund the Settlement Amount are conditioned upon:
(a) Receipt of fully executed originals (or true electronic copies pursuant to Section 9.7) of this Agreement;
(b) Receipt of any documents reasonably requested by Released Parties to ensure compliance with Medicare Secondary Payer Laws;
(c) Delivery of a completed Form W-9 for [PAYEE]; and
(d) Final Approval, if applicable under Section 3.6.
3.6 Minor or Incompetent Claimant. [Delete if inapplicable.]
If Claimant is a minor or has been adjudicated incompetent:
(a) Court Approval. This Agreement is subject to approval by the [__] Judicial District Court, [County], Wyoming, pursuant to Wyo. R. Civ. P. 17(c) and any applicable Wyoming statute.
(b) Conservatorship/Guardianship. Prior to payment, Claimant shall obtain entry of an order appointing a duly qualified conservator or guardian authorized to execute this Agreement and receive the Settlement Amount on Claimant’s behalf.
3.7 Taxes.
Claimant acknowledges that Released Parties have made no representation regarding the tax consequences of this settlement. Claimant agrees to assume full responsibility for any tax liability (other than any taxes attributable to Released Parties’ income or gross receipts) arising from the Settlement Amount.
4. REPRESENTATIONS & WARRANTIES
4.1 Mutual Reps. Each Party represents and warrants that:
(a) Authority. It has full power and authority to execute, deliver, and perform this Agreement.
(b) Enforceability. This Agreement constitutes a valid and binding obligation, enforceable against it in accordance with its terms.
(c) No Assignment. It has not assigned or transferred, or purported to assign or transfer, any Claim released herein.
4.2 Additional Representations of Claimant.
(a) Independent Counsel. Claimant has had the opportunity to consult independent legal counsel of Claimant’s choosing.
(b) No Reliance. Claimant is not relying on any statement or representation by Released Parties regarding liability, damages, or legal rights other than those expressly set forth in this Agreement.
(c) Health Care Reporting. Claimant has fully disclosed to Released Parties all known information necessary to comply with Medicare Secondary Payer Laws.
4.3 Survival. The representations and warranties in this Article 4 shall survive the Effective Date and shall not be merged into any court orders approving this Agreement.
5. COVENANTS & RESTRICTIONS
5.1 Confidentiality. [Optional] The Parties agree to maintain the confidentiality of the Settlement Amount and the terms herein, except as may be required by law, court order, or for tax, accounting, or lien-resolution purposes.
5.2 Non-Disparagement. Each Party agrees not to make any statement reasonably expected to disparage or harm the reputation of the other Party regarding matters released herein.
5.3 No Further Actions. Claimant covenants not to file, commence, or prosecute any action or proceeding arising out of the Incident against any Released Party.
6. DEFAULT & REMEDIES
6.1 Event of Default. Failure by a Party to perform any material obligation under this Agreement within five (5) business days after written notice and opportunity to cure shall constitute an “Event of Default.”
6.2 Remedies.
(a) Specific Performance. The non-breaching Party may seek specific enforcement of this Agreement.
(b) Judgment for Settlement Amount. If Released Parties fail to pay the Settlement Amount when due, Claimant may obtain a stipulated judgment for the unpaid portion of the Settlement Amount, plus interest at the statutory rate from the due date.
(c) Attorney Fees. The prevailing Party in any action to enforce this Agreement shall recover reasonable attorney fees and costs.
7. RISK ALLOCATION
7.1 Mutual Release.
(a) Release by Claimant. Upon receipt of the Settlement Amount, Claimant irrevocably and unconditionally releases and forever discharges the Released Parties from any and all Claims.
(b) Release by Released Parties. Upon payment of the Settlement Amount, Released Parties release Claimant from any claims relating solely to the filing or prosecution of the Action and consequent litigation costs.
(c) Scope. The Releases include all Claims whether known or unknown, suspected or unsuspected, and extend to future consequences of presently known or unknown injuries. Claimant expressly waives any principle of law that might otherwise limit the release of unknown Claims.
7.2 Indemnification for Liens. Claimant shall indemnify, defend, and hold harmless Released Parties from and against any and all liabilities, losses, and expenses (including reasonable attorney fees) arising out of or relating to any lien, subrogation interest, or claim for reimbursement asserted by a third party in connection with the Incident or Settlement Amount.
7.3 Limitation of Liability. The maximum aggregate liability of Released Parties under this Agreement shall not exceed the Settlement Amount.
7.4 Force Majeure. No Party shall be liable for delay or failure in performance caused by acts of God, war, terrorism, or any other cause beyond its reasonable control; provided, however, that financial inability shall not constitute force majeure.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Agreement and any dispute hereunder shall be governed by and construed in accordance with the laws of the State of Wyoming, without regard to its conflict-of-laws provisions.
8.2 Forum Selection. The Parties irrevocably submit to the exclusive jurisdiction of the state district courts of Wyoming located in [COUNTY] County for any action arising out of or relating to this Agreement.
8.3 Arbitration and Jury Trial. The Parties acknowledge that neither arbitration nor jury waiver provisions apply; any dispute shall be resolved in the designated Wyoming state court.
9. GENERAL PROVISIONS
9.1 Entire Agreement; Integration. This Agreement embodies the entire understanding of the Parties and supersedes all prior agreements and negotiations concerning its subject matter.
9.2 Amendments; 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 be deemed a waiver of any subsequent breach.
9.3 Assignment. No Party may assign or delegate its rights or obligations under this Agreement without the prior written consent of the other Party, except as expressly permitted in Section 3.2(c).
9.4 Severability. If any provision is held invalid or unenforceable, such provision shall be reformed to the minimum extent necessary to render it enforceable; the remaining provisions shall remain in full force and effect.
9.5 Successors and Assigns. This Agreement shall be binding upon and inure to the benefit of the Parties and their respective heirs, successors, and permitted assigns.
9.6 Counterparts. This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.
9.7 Electronic Signatures. Signatures transmitted by facsimile, e-mail (PDF), or via an electronic signature platform (e.g., DocuSign) shall be deemed originals for all purposes.
9.8 Headings. Headings are for reference purposes only and shall not affect the interpretation of this Agreement.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the Parties have executed this Agreement as of the Effective Date.
| CLAIMANT | ||
|---|---|---|
| ______ | Date: _____ | |
| Name: [CLAIMANT NAME] |
| RELEASED PARTIES | ||
|---|---|---|
| ______ | Date: _____ | |
| Name: [AUTHORIZED SIGNATORY] | Title: [TITLE] |
[Optional Notary Acknowledgment – Wyoming]
State of Wyoming )
County of [__] )
The foregoing instrument was acknowledged before me on [DATE] by [NAME(S)].
Notary Public
My Commission Expires: ______
EXHIBIT A – Structured Settlement Payment Schedule
[Insert periodic payment table or attach annuity contract summary.]
[// GUIDANCE: Attach additional schedules for lien resolution, medical expense ledger, or court-approval documents as needed.]