Release of All Claims - Arkansas

RELEASE OF ALL CLAIMS

(State of Arkansas)

1. PARTIES

This Release of All Claims (this "Release") is made and entered into on [__/__/____] by and between:

The person responsible for the Settlement Sum is [PAYER LEGAL NAME] ("Payer"), whose signature appears below. The Payer is [Releasee / Insurer / Other: __________].

For purposes of this Release, "Released Parties" means the Releasee(s) named above and each of their respective past, present, and future agents, servants, employees, officers, directors, principals, partners, insurers (including the Insurer), reinsurers, predecessors, successors, heirs, assigns, parent and affiliated entities, attorneys, and representatives.

2. RECITALS

A. On or about [__/__/____], at or near [________________________________] (the "Incident"), the Releasor allegedly sustained bodily injuries, damages, and losses arising out of [describe incident — e.g., motor vehicle collision, premises condition].

B. The Releasor has asserted or may assert a claim for damages against the Releasee(s) arising out of the Incident. The claim is identified as Claim No. [________________________________] under Policy No. [________________________________] issued by the Insurer.

C. The Parties desire to fully and finally compromise, settle, and resolve all claims arising out of the Incident, without further litigation and without any admission of liability.

3. CONSIDERATION

In consideration for this Release, the Payer shall pay the total sum of [AMOUNT IN WORDS] Dollars ($[____]) (the "Settlement Sum") by [PAYMENT METHOD] no later than [__/__/____], unless the court-approved payment route in Section 12 applies. This Release takes effect only when the full Settlement Sum is received in cleared funds by the Releasor or the court-approved recipient. The Releasor acknowledges receipt and sufficiency of the consideration only upon that payment. The Releasor agrees that the Settlement Sum constitutes the entire consideration for this Release and that no other promise or inducement has been made.

4. RELEASE OF ALL CLAIMS (KNOWN AND UNKNOWN)

4.1 General Release. In consideration of the Settlement Sum, the Releasor hereby releases, acquits, and forever discharges the Released Parties from any and all claims, demands, actions, causes of action, damages, costs, loss of services, expenses, and compensation of every kind and nature whatsoever, whether in contract or in tort, whether known or unknown, suspected or unsuspected, anticipated or unanticipated, fixed or contingent, that the Releasor owns now or may hereafter own arising out of or in any way connected with the Incident, including all known and unknown injuries and all future developments, consequences, or complications thereof. This Release does not purport to discharge a lien or reimbursement right held by a person who is not a party to it; Section 7 addresses identified interests.

4.2 Unknown Claims. The Releasor understands and agrees that this Release extends to claims the Releasor does not know or suspect to exist at the time of execution, and that the discovery of additional or different facts or injuries shall not affect the finality of this Release. The Releasor expressly assumes the risk that the injuries or damages may be more numerous or more serious than now known or expected.

5. EFFECT ON OTHER TORTFEASORS / RESERVATION OF CLAIMS

Select one:

☐ Reservation (release of settling parties only). This Release discharges only the Released Parties named herein. The Releasor expressly reserves all claims against any other person or entity who may be liable for the Incident. Pursuant to Ark. Code § 16-61-204, this Release shall not discharge any other joint tortfeasor. Damages recoverable against other joint tortfeasors will be reduced by the greatest of the consideration paid for this Release, the released joint tortfeasor's pro rata share of responsibility as determined by the finder of fact, or any greater reduction stated in this Release. This Release provides for at least the pro rata reduction required by § 16-61-204(b); relief from contribution remains subject to that section's timing and other conditions.

☐ General release (all tortfeasors). This Release is intended to and does, by its terms, discharge all persons and entities liable or claimed to be liable for the Incident, whether named herein or not.

6. NO ADMISSION OF LIABILITY

It is understood and agreed that this settlement is a compromise of a doubtful and disputed claim, that payment is not to be construed as an admission of liability on the part of any of the Released Parties, and that the Released Parties expressly deny liability and intend merely to avoid the expense and uncertainty of litigation.

7. MEDICAL LIENS, SUBROGATION, AND MEDICARE / MEDICAID (MSP) ACKNOWLEDGMENT

7.1 Asserted-Interest Inventory. Identify each asserted interest, holder, amount, dispute status, and proposed payoff, holdback, escrow, or direct-payment instruction in [ATTACHMENT / DETAILS]. Listing an interest does not admit its validity, amount, priority, or allocation.

7.2 Medicare Secondary Payer. The Releasor represents that the Releasor [☐ is / ☐ is not] a Medicare beneficiary and [☐ has / ☐ has not] applied for Social Security disability or Medicare benefits. If Medicare made a conditional payment for an item or service included in this claim and a primary plan's payment responsibility is demonstrated, the Parties will identify the payment and document the applicable reimbursement arrangement under 42 U.S.C. § 1395y(b) in [ATTACHMENT / DETAILS]. Any arrangement for future medical expenses must be separately reviewed and stated; this Release assumes no automatic set-aside or CMS approval process.

7.3 Asserted-Interest Resolution. Record each asserted lien, reimbursement, or recovery interest and the agreed payoff, direct payment, holdback, escrow, or dispute procedure in [ATTACHMENT / DETAILS]. No blanket indemnity, defense duty, penalty shift, or attorney-fee obligation is created by this form; any negotiated allocation must be separately stated and reviewed.

8. DERIVATIVE, SPOUSAL, AND CONSORTIUM CLAIMS

This Release covers only claims owned by the Releasor. A spouse or other person who independently holds a claim is included only if that person is identified as an additional releasor, the claim is described here [________________________________], and that person signs this Release in that capacity.

9. REPRESENTATIONS AND WARRANTIES

The Releasor represents and warrants that the Releasor:

a. has not assigned, pledged, or transferred any claim released herein to any other person or entity;
b. is of legal age and sound mind and competent to execute this Release (see Section 12 if the Releasor is a minor or incapacitated person);
c. has read this Release in full, understands its terms, and signs it voluntarily;
d. has had the opportunity to consult with independent legal counsel of the Releasor's choosing; and
e. is not relying on any statement or representation not contained in this Release.

10. CONFIDENTIALITY (OPTIONAL)

☐ The Parties agree to keep the terms and amount of this settlement confidential, except as required by law, for tax or lien-resolution purposes, or to enforce this Release.

11. GOVERNING LAW

This Release shall be governed by and construed in accordance with the laws of the State of Arkansas, without regard to its conflict-of-laws principles. If any provision is held unenforceable, the remaining provisions shall continue in full force and effect.

12. MINOR'S OR INCAPACITATED PERSON'S COMPROMISE

☐ The Releasor is a minor or incapacitated person. This Release is executed by [NAME OF GUARDIAN / NEXT FRIEND], as [guardian of the estate / next friend] of [MINOR/WARD NAME], and is subject to and conditioned upon approval by a court of competent jurisdiction pursuant to Ark. Code § 28-65-318 and applicable Arkansas law. This Release shall not be binding on the minor or incapacitated person unless and until so approved.

If this box is checked, the Payer shall pay within [____] days after the approval order becomes effective, to the recipient or account the court authorizes: [COURT-APPROVED PAYMENT DETAILS]. The release also remains conditioned on the full cleared payment required by Section 3.

Court / Case No. (if approved): [________________________________]

13. EXECUTION

IN WITNESS WHEREOF, the Releasor has executed this Release of All Claims on the date set forth below.

RELEASOR

Signature: _______________________________
Printed Name: [________________________________]
Date: [__/__/____]

PAYER (accepting the payment obligation in Section 3)

Signature: _______________________________
Printed name and capacity: [________________________________]
For: [PAYER LEGAL NAME]
Date: [__/__/____]

STATE OF ARKANSAS
COUNTY OF [________________]

Before me, the undersigned authority, personally appeared [________________________________], who is known to me or who produced [________________________________] as identification, and who acknowledged before me that he/she executed the foregoing Release of All Claims freely and voluntarily for the purposes therein expressed.

Subscribed and sworn to before me this [____] day of [____________], [____].

_______________________________
Notary Public
My Commission Expires: [__/__/____]

Sources and References

• Ark. Code § 16-61-204 — Release: effect on injured person's claim and on right of contribution: https://arkleg.state.ar.us/Acts/FTPDocument?path=%2FACTS%2F2013%2FPublic%2F&file=1116.pdf&ddBienniumSession=2013%2F2013R
• Ark. Code § 16-61-202 — Right of contribution among joint tortfeasors: https://law.justia.com/codes/arkansas/title-16/subtitle-5/chapter-61/subchapter-2/
• Ark. Code § 28-65-318 — Compromise settlements (guardian/ward): https://law.justia.com/codes/arkansas/title-28/subtitle-5/chapter-65/subchapter-3/section-28-65-318/
• Medicare Secondary Payer Act, 42 U.S.C. § 1395y(b): https://uscode.house.gov/us/usc/119-136/t42/s1395y/