Release and Settlement Agreement

RELEASE AND SETTLEMENT AGREEMENT

This Agreement is made on [__/__/____] among the persons who sign below.

Claimant / releasing party: [FULL NAME AND ADDRESS]
Other claimant signing, if any: [NAME, CAPACITY, AND ADDRESS OR “NONE”]
Settling defendant or other released person: [EACH NAME AND CAPACITY]
Payor and capacity: [INSURER / DEFENDANT / OTHER PERSON, NAME AND ADDRESS]
Claim or case: [INCIDENT DATE, LOCATION, COURT, CASE NUMBER, AND CLAIM NUMBER]

The parties dispute [BRIEF DESCRIPTION OF CLAIM AND DEFENSE]. They wish to resolve only the claims described here without an admission of fault.

1. Settlement payment

The payor will pay $[TOTAL AMOUNT] to [PAYEE AND DELIVERY INSTRUCTIONS] by [EXACT DATE OR EVENT]. If payment is structured or includes noncash consideration, the complete schedule, obligor, security, and delivery terms are in Exhibit [__] and are part of this Agreement.

Required action before payment: [SIGNATURE / COURT APPROVAL / OTHER IDENTIFIED EVENT OR “NONE”]
Payment confirmation method: [CLEARED FUNDS / OTHER OBJECTIVE METHOD]
If payment is late: [NOTICE ADDRESS, CURE PERIOD IF AGREED, AND SPECIFIC REMEDY]

No settlement amount in this Agreement includes a separate claimant’s or independent third party’s claim unless that person signs and the claim is expressly identified.

2. Defined release

Claims released: [IDENTIFY CLAIMS ARISING FROM THE SPECIFIED INCIDENT, INCLUDING ANY PROPERTY OR DERIVATIVE CLAIM ONLY IF THE OWNER SIGNS]

Persons released: [IDENTIFY EACH PERSON OR ENTITY BY NAME OR PRECISELY DEFINED CLASS]

Claims and persons expressly reserved: [LIST, INCLUDING ANY UM/UIM OR SEPARATE CLAIM, OR WRITE “NONE”]

Release takes effect (choose one): ☐ When the full settlement consideration is received as cleared funds ☐ On [OTHER PRECISE EVENT]

At the selected effective event, each signing claimant releases only the identified claims against only the identified released persons. No person who does not sign purports to release another person’s independent claim. Claims to enforce this Agreement are reserved.

Unknown or unsuspected claims: ☐ No separate waiver is included; the defined release above controls. ☐ A specifically identified state-law waiver is set out in Exhibit [__], separately reviewed and signed or initialed as required by the selected law. Governing state and source: [STATE AND CURRENT AUTHORITY]

3. Medical bills and reimbursement interests

The parties identify the interests currently known to them. An amount marked disputed or pending is not represented as paid or finally resolved.

Medicare conditional-payment status, if relevant: [BENEFICIARY STATUS; CASE IDENTIFIER; FINAL DEMAND, DISPUTE, OR PENDING STATUS]
Medicaid or other public-benefit issue, if relevant: [IDENTIFY STATUS AND RESPONSIBLE PERSON]
Any future-medical allocation or set-aside separately agreed: [REFERENCE AGREEMENT OR “NONE”]

Responsibility for obtaining final figures and making the listed payments: [EXACT PERSON AND TIMING]. Amount held pending resolution, if any: $[____] by [HOLDER AND RELEASE CONDITION]. No party guarantees that an unidentified third party has no claim. Any indemnity is limited to the following identified obligation and agreed cap, if selected: [PRECISE TERM OR “NONE”].

4. Case disposition and approvals

Pending action: ☐ None ☐ [COURT, CASE NUMBER, AND PARTIES]

After [CLEARED PAYMENT / OTHER SELECTED EVENT], [PERSON] will file or deliver [SPECIFIC DISMISSAL OR STIPULATION] within [NUMBER] days. It will dispose of [IDENTIFIED CLAIMS/PARTIES]. Each party bears its own fees and costs except [PRECISE EXCEPTION OR “NONE”].

Approval required before this Agreement can take effect, if any: [COURT/AGENCY, BASIS, WHO APPLIES, AND CONSEQUENCE OF NONAPPROVAL OR “NONE”]

Release or settlement document still to be signed, if any: [NAME AND ATTACHMENT OR “NONE”]

5. Other agreed terms

Confidentiality: [EXACT SUBJECT, PERMITTED DISCLOSURES, DURATION, AND REMEDY IF AGREED; OTHERWISE “NONE”]

Non-disparagement or other conduct term: [EXACT TERM OR “NONE”]

Representation concerning assignment or authority: Each signing claimant states only that [FACTUAL REPRESENTATION AGREED FOR THIS CLAIM, INCLUDING DISCLOSED ASSIGNMENTS OR “NONE”]. Each person signing for an entity states their capacity and authority below.

Governing law: [STATE]
Forum or agreed dispute process: [COURT/PROCESS AND ANY REQUIRED CONSENT OR “NONE”]
Notices under this Agreement: [EACH PARTY'S ADDRESS AND DELIVERY METHOD]

This Agreement and its listed exhibits contain the parties’ settlement terms. Changes require a writing signed by the affected parties. If one provision cannot be enforced, the remaining terms operate only to the extent they can still carry out the parties’ agreed settlement.

Signatures

By signing, each party agrees to the precise payment, release, and other obligations assigned to that party above.

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

Additional claimant signature, if any: [________________________________] Date: [__/__/____]
Printed name and capacity: [________________________________]

Settling defendant or releasee signature: [________________________________] Date: [__/__/____]
Printed name and capacity: [________________________________]

Payor or insurer signature, if separately obligated: [________________________________] Date: [__/__/____]
Printed name, organization, and capacity: [________________________________]

Other required signer or court-approved representative: [________________________________] Date: [__/__/____]
Printed name and authority: [________________________________]

Exhibits incorporated: [LIST BY NUMBER AND TITLE OR “NONE”]