RELEASE AND SETTLEMENT AGREEMENT

Personal Injury Claim Resolution

PARTIES

RELEASOR (Claimant):
Name: [________________________________]
Address: [________________________________]
City, State, Zip: [________________________________]
Date of Birth: [________________________________]
Social Security Number: [________________________________]

RELEASEE(S) (Released Party/Parties):

Releasee 1:
Name: [________________________________]
Address: [________________________________]
City, State, Zip: [________________________________]

Releasee 2 (if applicable):
Name: [________________________________]
Address: [________________________________]

INSURANCE CARRIER:
Name: [________________________________]
Claim Number: [________________________________]
Policy Number: [________________________________]

RECITALS

A. On or about [DATE OF INCIDENT], an incident occurred at [LOCATION] (the "Incident").

B. Releasor claims to have suffered personal injuries and damages as a result of the Incident.

C. Releasee(s) deny liability for the Incident and any resulting injuries or damages.

D. The parties desire to settle and compromise all claims arising from the Incident without admission of liability.

E. This Agreement represents a compromise of disputed claims and is not an admission of liability.

AGREEMENT

NOW, THEREFORE, in consideration of the payment described herein and the mutual promises contained in this Agreement, the parties agree as follows:

1. SETTLEMENT PAYMENT

1.1 Settlement Amount

In consideration of this Release, Releasee(s) and/or their insurance carrier agree to pay Releasor the total sum of:

$[________________________________] ([AMOUNT IN WORDS] DOLLARS)

1.2 Form of Payment

Payment shall be made by:

☐ Check payable to: [________________________________]
☐ Wire transfer to: [________________________________]
☐ Structured settlement as set forth in Exhibit A

1.3 Payment Delivery

Payment shall be delivered to:

[LAW FIRM NAME]
[ADDRESS]
[CITY, STATE ZIP]
Attn: [________________________________]

1.4 Payment Timing

Payment shall be made within [___] days of:

☐ Execution of this Agreement
☐ Delivery of this fully executed Agreement to [INSURANCE CARRIER]
☐ Court approval (if required)
☐ Other: [________________________________]

2. RELEASE OF CLAIMS

2.1 General Release

For and in consideration of the payment described above, Releasor, for himself/herself and his/her heirs, executors, administrators, successors, and assigns, hereby releases, acquits, and forever discharges:

• [RELEASEE NAME(S)]
• Their heirs, executors, administrators, successors, and assigns
• Their agents, servants, employees, and representatives
• Their insurance carriers and their agents
• All other persons, firms, or corporations liable or who might be claimed to be liable

from any and all claims, demands, damages, actions, causes of action, or suits of any kind or nature whatsoever, whether known or unknown, which Releasor now has or may hereafter have, arising out of or in any way connected with the Incident that occurred on or about [DATE].

2.2 Scope of Release

This Release includes, but is not limited to, claims for:

☐ Personal injuries (bodily injury)
☐ Pain and suffering
☐ Mental anguish and emotional distress
☐ Medical expenses (past and future)
☐ Lost wages and loss of earning capacity
☐ Loss of consortium (if applicable)
☐ Property damage
☐ Punitive or exemplary damages
☐ Any other damages of any kind

2.3 Unknown Claims

WAIVER OF UNKNOWN CLAIMS:

Releasor expressly waives all rights under California Civil Code Section 1542 (or similar statutes of other jurisdictions), which provides:

"A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS THAT THE CREDITOR OR RELEASING PARTY DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE AND THAT, IF KNOWN BY HIM OR HER, WOULD HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR OR RELEASED PARTY."

Releasor acknowledges that [he/she] may discover facts different from or in addition to those [he/she] now knows or believes to be true regarding the Incident and the injuries and damages arising therefrom, and Releasor expressly agrees to assume the risk of such possible differences in fact.

☐ Releasor initials acknowledging waiver of unknown claims: [____]

3. SPECIFIC PROVISIONS

3.1 No Admission of Liability

This Agreement is a compromise of disputed claims. Neither this Agreement nor the payment of any consideration hereunder shall be construed as an admission of liability or fault by any Releasee.

3.2 Claims Not Released

This Release does NOT release or discharge:

☐ Claims against parties not named herein
☐ Claims for future medical treatment against health insurers
☐ Uninsured/Underinsured Motorist claims (if preserved): [________________________________]
☐ Other: [________________________________]

3.3 Third-Party Claims

☐ Releasor agrees to indemnify and hold harmless Releasee(s) from any claims made by third parties arising from the Incident.

☐ This Release does not affect the rights of third parties with independent claims.

4. LIENS AND SUBROGATION

4.1 Medicare/Medicaid Compliance

[// GUIDANCE: Critical section for Medicare Secondary Payer compliance]

Medicare Status:

☐ Releasor is NOT a Medicare beneficiary.

☐ Releasor IS a Medicare beneficiary.
- Medicare Number: [________________________________]
- Conditional payments have been resolved: ☐ Yes ☐ Pending
- Final demand amount: $[________________________________]
- Payment to Medicare: $[________________________________]

Medicaid Status:

☐ Releasor is NOT a Medicaid beneficiary.

☐ Releasor IS a Medicaid beneficiary.
- State: [________________________________]
- Lien amount: $[________________________________]
- Payment to Medicaid: $[________________________________]

4.2 Medicare Set-Aside (if applicable)

☐ Not applicable

☐ A Medicare Set-Aside (MSA) in the amount of $[________] has been established/will be established to protect Medicare's interests for future medical expenses.

4.3 Health Insurance Liens

Releasor represents that [he/she] has disclosed all health insurance providers that have paid or may claim reimbursement for injuries from the Incident:

4.4 Other Liens

Releasor represents that all other liens have been identified and will be resolved:

4.5 Indemnification for Liens

Releasor agrees to indemnify, defend, and hold harmless Releasee(s) and their insurance carrier from any claims, liens, or demands for payment by any person or entity claiming a right to payment from the settlement proceeds, including but not limited to Medicare, Medicaid, health insurers, hospitals, physicians, and any other healthcare providers.

5. REPRESENTATIONS AND WARRANTIES

5.1 Releasor's Representations

Releasor represents and warrants that:

(a) [He/She] is the lawful owner of the claims released herein.

(b) [He/She] has not assigned, transferred, or encumbered any claims released herein.

(c) [He/She] has disclosed all liens and subrogation claims of which [he/she] is aware.

(d) [He/She] has full legal authority to execute this Agreement.

(e) [He/She] has read this Agreement and fully understands its terms.

(f) [He/She] has had the opportunity to consult with an attorney.

(g) [He/She] is executing this Agreement voluntarily and without coercion.

(h) No promise or inducement has been made other than those contained herein.

(i) The information provided regarding Medicare/Medicaid status is true and accurate.

5.2 Releasee's Representations

Releasee(s) represent(s) and warrant(s) that:

(a) The payment described herein represents the full and final payment in settlement of this claim.

(b) [If applicable] The policy limits have been exhausted: ☐ Yes ☐ No

6. DISMISSAL OF PENDING ACTIONS

[// GUIDANCE: Include if lawsuit has been filed]

☐ Not applicable (no lawsuit filed)

☐ Applicable:

Within [___] days of receipt of the settlement payment, Releasor shall file a Request for Dismissal with Prejudice of the following action(s):

Case Caption: [________________________________]
Case Number: [________________________________]
Court: [________________________________]

Each party shall bear its own attorney fees and costs unless otherwise agreed.

7. CONFIDENTIALITY

☐ Not applicable

☐ Applicable:

The parties agree to keep the terms of this Agreement confidential, except as required by law or to enforce the terms hereof. This confidentiality provision does not prevent disclosure to:

• Attorneys, accountants, and financial advisors
• Immediate family members
• Government agencies as required by law
• Courts as necessary to enforce this Agreement

8. NON-DISPARAGEMENT

☐ Not applicable

☐ Applicable:

The parties agree not to make any disparaging statements about one another in connection with the Incident or this settlement.

9. GENERAL PROVISIONS

9.1 Entire Agreement

This Agreement constitutes the entire agreement between the parties and supersedes all prior discussions, negotiations, and agreements.

9.2 Amendments

This Agreement may only be amended by a written document signed by all parties.

9.3 Governing Law

This Agreement shall be governed by the laws of the State of [________________________________].

9.4 Severability

If any provision of this Agreement is found invalid or unenforceable, the remaining provisions shall continue in full force and effect.

9.5 Counterparts

This Agreement may be executed in counterparts, each of which shall be deemed an original.

9.6 Electronic Signatures

Electronic signatures shall be deemed valid and binding.

9.7 Headings

Section headings are for convenience only and shall not affect interpretation.

9.8 Binding Effect

This Agreement is binding upon the parties and their heirs, executors, administrators, successors, and assigns.

10. ADVICE OF COUNSEL

Releasor acknowledges that:

☐ [He/She] has been represented by [ATTORNEY NAME] in this matter.

☐ [He/She] has been advised to seek legal counsel and has chosen to proceed without representation.

Releasor understands the legal significance of this Release and executes it voluntarily.

11. ADDITIONAL TERMS

[Insert any additional terms specific to this settlement:]

☐ Not applicable

☐ Additional terms:
[________________________________]
[________________________________]
[________________________________]

SIGNATURES

RELEASOR:

I HAVE READ THIS RELEASE AND SETTLEMENT AGREEMENT, UNDERSTAND ITS CONTENTS, AND SIGN IT VOLUNTARILY.

Signature: _________________________________ Date: ______________

Printed Name: _________________________________

RELEASOR'S ATTORNEY (if applicable):

Signature: _________________________________ Date: ______________

Printed Name: _________________________________

Firm: _________________________________

RELEASEE (if signing):

Signature: _________________________________ Date: ______________

Printed Name: _________________________________

Title: _________________________________

INSURANCE CARRIER REPRESENTATIVE (if signing):

Signature: _________________________________ Date: ______________

Printed Name: _________________________________

Title: _________________________________

Company: _________________________________

NOTARIZATION (if required)

STATE OF [________________]
COUNTY OF [________________]

On this [____] day of [________________], 20[____], before me personally appeared [________________________________], known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument and acknowledged to me that [he/she] executed the same in [his/her] authorized capacity, and that by [his/her] signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument.

WITNESS my hand and official seal.

Notary Public Signature: _________________________________

My Commission Expires: _________________________________

[NOTARY SEAL]

EXHIBIT A: STRUCTURED SETTLEMENT TERMS (if applicable)

[Attach structured settlement documents if applicable]

EXHIBIT B: LIEN RESOLUTION SUMMARY