General Release of Claims

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GENERAL RELEASE OF ALL CLAIMS

Commonwealth of Pennsylvania

NOTICE: This is a legally binding document. By signing this Release, the Releasor permanently gives up the right to pursue any claims against the Released Parties arising from the incident described below. Once signed, this Release generally cannot be revoked. The Releasor should read this document carefully and consult with an attorney before signing.

Parties and Identification
Recitals
Definitions
Consideration
Release of Claims
Scope of Release
Medicare and Government Benefits Compliance
Workers' Compensation and Subrogation
Minor's Release (If Applicable)
Representations and Warranties
Covenant Not to Sue
Indemnification
Confidentiality
Non-Disparagement
Tax Implications
General Provisions
Execution Block
Notary Acknowledgment (Optional)

1. PARTIES AND IDENTIFICATION

A. Releasor (Person Releasing Claims)

Field	Information
Full Legal Name	[________________________________]
Date of Birth	[__/__/____]
Address	[________________________________]
City, State, ZIP	[________________________________], Pennsylvania [____]
County	[________________________________]
Telephone	[________________________________]
Social Security Number (last 4)	XXX-XX-[____]

B. Releasee (Person Being Released)

Field	Information
Full Legal Name	[________________________________]
Address	[________________________________]
City, State, ZIP	[________________________________]
Insurance Company	[________________________________]
Claim/Policy Number	[________________________________]

C. Additional Releasee(s) (if applicable)

Full Legal Name	Relationship	Address
[________________________________]	[________________________________]	[________________________________]
[________________________________]	[________________________________]	[________________________________]

2. RECITALS

A. On or about [__/__/____], an incident occurred at or near [________________________________], [________________________________] County, Pennsylvania (the "Incident"), in which Releasor claims to have sustained personal injuries, property damage, and other losses.

B. The nature of the Incident was: ☐ Motor vehicle accident ☐ Slip and fall / premises liability ☐ Product liability ☐ Medical malpractice ☐ Assault/battery ☐ Dog bite ☐ Other: [________________________________]

C. Releasor asserts that Releasee and/or the Released Parties (defined below) are liable for damages arising from the Incident.

D. ☐ Litigation is currently pending: Case No. [________________________________], Court of Common Pleas, [________________________________] County / U.S. District Court, [________________________________] District of Pennsylvania.
☐ No litigation has been filed.

E. The parties desire to fully, finally, and permanently resolve all claims, demands, and causes of action between them arising from or related to the Incident, without any admission of liability.

F. In consideration of the payment described below and the mutual covenants contained herein, and intending to be legally bound, the parties agree as follows:

3. DEFINITIONS

"Claims" means any and all claims, demands, actions, causes of action, suits, rights, debts, obligations, liabilities, damages (compensatory, punitive, and consequential), losses, costs, expenses, liens, and attorneys' fees of every kind and nature, whether known or unknown, suspected or unsuspected, disclosed or undisclosed, asserted or unasserted, liquidated or unliquidated, fixed or contingent, matured or unmatured, in law, equity, or otherwise, arising from or related to the Incident and occurring on or before the Effective Date.

"Effective Date" means the date this Release is last executed by the parties.

"Incident" means the event described in Section 2(A) above.

"Released Parties" means the Releasee and all of the following, whether past, present, or future: parents, subsidiaries, affiliates, divisions, officers, directors, shareholders, members, partners, employees, servants, agents, representatives, contractors, subcontractors, insurers, reinsurers, underwriters, predecessors, successors, assigns, heirs, executors, administrators, legal representatives, and attorneys.

"Releasor" includes the person identified in Section 1(A) and that person's heirs, executors, administrators, successors, assigns, agents, representatives, and any person claiming through or under Releasor.

4. CONSIDERATION

4.1. In consideration for the execution of this Release, Releasee (or Releasee's insurer) shall pay to Releasor the total sum of $[________________________________] (the "Settlement Amount"), payable as follows:

☐ Lump Sum: The full Settlement Amount shall be paid by check, wire transfer, or electronic payment within [____] business days after receipt of the fully executed Release.

☐ Structured Settlement: The Settlement Amount shall be paid in periodic payments as follows:

Initial payment of $[________________________________] due within [____] business days
Subsequent payments as set forth in the attached Structured Settlement Agreement (Exhibit A)

4.2. Method of Payment:
☐ Check payable to: [________________________________]
☐ Check payable to: [________________________________] Attorney Trust Account
☐ Wire transfer to: [________________________________]
☐ Other: [________________________________]

4.3. Allocation of Settlement Amount:

Category	Amount
Past medical expenses	$[________________________________]
Future medical expenses	$[________________________________]
Past lost wages / earning capacity	$[________________________________]
Future lost wages / earning capacity	$[________________________________]
Pain and suffering / emotional distress	$[________________________________]
Property damage	$[________________________________]
Attorneys' fees	$[________________________________]
Costs and expenses	$[________________________________]
Other: [________________________________]	$[________________________________]
Total	$[________________________________]

4.4. Releasor acknowledges that the Settlement Amount constitutes adequate and sufficient consideration under Pennsylvania law and that this Release is not unconscionable.

5. RELEASE OF CLAIMS

5.1. General Release. Releasor, for and on behalf of Releasor and Releasor's heirs, executors, administrators, successors, and assigns, does hereby IRREVOCABLY AND UNCONDITIONALLY RELEASE, ACQUIT, AND FOREVER DISCHARGE the Released Parties from any and all Claims, as defined herein, arising from or related to the Incident.

5.2. Known and Unknown Claims. Releasor expressly waives and relinquishes any right or benefit under any statute, rule, or legal doctrine that might otherwise limit the scope of this Release to Claims that are known, suspected, or anticipated at the time of execution. THIS RELEASE COVERS BOTH KNOWN AND UNKNOWN CLAIMS.

5.3. Pennsylvania Enforceability. Releasor acknowledges that Pennsylvania courts enforce broadly worded releases of unknown claims provided the release language is clear, specific, and conspicuous. See Buttermore v. Aliquippa Hospital, 561 A.2d 733 (Pa. 1989); Employers Liability Assurance Corp. v. Greenville Business Men's Ass'n, 224 Pa. Super. 520 (1973).

6. SCOPE OF RELEASE

6.1. This Release encompasses Claims for, including but not limited to:

☐ Personal injury (bodily injury, physical pain, mental anguish, emotional distress)
☐ Medical expenses (past and future)
☐ Lost wages and loss of earning capacity (past and future)
☐ Property damage
☐ Loss of consortium (including claims of Releasor's spouse)
☐ Disfigurement and scarring
☐ Disability and impairment
☐ Wrongful death and survival claims (if applicable)
☐ Punitive and exemplary damages
☐ Attorneys' fees and costs
☐ All other damages of every kind

6.2. No Admission of Liability. This Release is a compromise of disputed claims. Nothing herein constitutes or shall be construed as an admission of liability, fault, negligence, or wrongdoing by any Released Party.

6.3. Comparative Negligence (42 Pa. C.S. § 7102). Pennsylvania follows a modified comparative negligence standard (51% bar rule). Releasor acknowledges that this Release fully and finally resolves all questions of comparative fault.

7. MEDICARE AND GOVERNMENT BENEFITS COMPLIANCE

A. Medicare Secondary Payer Act Compliance (42 U.S.C. § 1395y(b))

7.1. Releasor represents that as of the Effective Date:

☐ Releasor is NOT currently a Medicare beneficiary and has no reasonable expectation of becoming a Medicare beneficiary within thirty (30) months of the Effective Date.

☐ Releasor IS a Medicare beneficiary. The following Medicare compliance steps have been taken:

Medicare's interests have been identified through a conditional payment inquiry to the Benefits Coordination & Recovery Center (BCRC)
Medicare conditional payments totaling $[________________________________] have been identified
Arrangements for repayment of Medicare conditional payments have been made
☐ A Medicare Set-Aside (MSA) arrangement ☐ has been / ☐ has not been established for future medical expenses
☐ CMS approval of the MSA ☐ has been obtained / ☐ has been requested / ☐ is not required

7.2. Releasor agrees to comply with all applicable Medicare Secondary Payer Act requirements, including repayment of any conditional payments and, if applicable, proper administration of any MSA arrangement.

7.3. Releasor shall indemnify and hold harmless the Released Parties from any liability, claim, demand, or penalty arising from Releasor's failure to comply with Medicare requirements.

B. Medicaid and Other Government Benefits

7.4. ☐ Releasor has received Medicaid benefits related to the Incident. Medicaid's lien/claim in the amount of $[________________________________] has been addressed as follows: [________________________________]

7.5. ☐ Releasor has received other government benefits (VA, TRICARE, etc.) related to the Incident: [________________________________]

8. WORKERS' COMPENSATION AND SUBROGATION

8.1. ☐ No Workers' Compensation. The Incident did not arise in the course and scope of employment, and no workers' compensation benefits have been paid or claimed.

8.2. ☐ Workers' Compensation Lien. Workers' compensation benefits have been paid by [________________________________] in connection with the Incident. The workers' compensation lien in the amount of $[________________________________] has been resolved as follows: [________________________________]

8.3. Under 42 Pa. C.S. § 8371 and 77 Pa. C.S. § 671 (Workers' Compensation Act subrogation), any applicable lien must be satisfied or resolved before or simultaneously with this Release.

8.4. ☐ Health Insurance Subrogation. Releasor's health insurer, [________________________________], has a subrogation claim of $[________________________________], which has been resolved as follows: [________________________________]

8.5. ☐ Motor Vehicle Insurance Subrogation (75 Pa. C.S. § 1720). Applicable motor vehicle insurance subrogation rights have been addressed as follows: [________________________________]

9. MINOR'S RELEASE (IF APPLICABLE)

☐ Not Applicable. Releasor is an adult (18 years of age or older).

☐ Minor's Release. Releasor is a minor (under 18 years of age). The following apply:

9.1. Under Pa. R.C.P. 2039, any settlement of a minor's claim must be approved by the Court of Common Pleas.

9.2. Guardian Information:

Field	Information
Guardian Name	[________________________________]
Relationship	[________________________________]
Address	[________________________________]

9.3. ☐ A Petition to Approve Minor's Settlement has been filed in the Court of Common Pleas, [________________________________] County, Case No. [________________________________].

9.4. ☐ Court approval was obtained on [__/__/____]. A copy of the Court Order is attached as Exhibit B.

9.5. The Settlement Amount for the minor shall be:
☐ Deposited in a restricted account at [________________________________] (financial institution), not to be withdrawn until the minor reaches age 18
☐ Used to purchase an annuity for the minor
☐ Distributed as directed by the Court Order

10. REPRESENTATIONS AND WARRANTIES

Releasor represents and warrants that:

10.1. Authority. Releasor has full power and legal authority to execute this Release and to bind all persons and entities on whose behalf Releasor is acting.

10.2. No Assignment. Releasor has not assigned, transferred, conveyed, or encumbered any Claim to any third party. No other person or entity has a right to assert any Claim released herein, except as disclosed.

10.3. Independent Counsel. Releasor has had the opportunity to consult with independent legal counsel regarding this Release and its consequences.
☐ Releasor is represented by: [________________________________], Esq.
☐ Releasor has chosen to proceed without legal counsel.

10.4. Voluntariness. Releasor executes this Release voluntarily, without duress, coercion, or undue influence.

10.5. Understanding. Releasor has read this Release in its entirety, understands its terms and legal effect, and signs it as a free and voluntary act.

10.6. Liens and Obligations. Releasor has disclosed all liens, subrogation claims, and reimbursement obligations known to Releasor, including Medicare, Medicaid, workers' compensation, and health insurance liens.

10.7. Accuracy. All information provided by Releasor in connection with this Release is true, complete, and accurate.

11. COVENANT NOT TO SUE

11.1. Releasor covenants and agrees that Releasor will not hereafter commence, maintain, prosecute, or voluntarily assist in any action, lawsuit, arbitration, or proceeding of any kind against any Released Party based upon any Claim released herein.

11.2. If Releasor breaches this covenant, Releasor shall:

Immediately reimburse the Released Parties for the full Settlement Amount
Indemnify the Released Parties for all costs, expenses, and attorneys' fees incurred in defending against the breach
Be liable for any additional damages resulting from the breach

11.3. Joint Tortfeasor Contribution (42 Pa. C.S. § 7104). This Release ☐ is / ☐ is not intended to release joint tortfeasors. If not releasing joint tortfeasors, Releasor reserves the right to pursue claims against: [________________________________]

12. INDEMNIFICATION

12.1. Releasor shall indemnify, defend, and hold harmless the Released Parties from and against any and all claims, demands, liens, actions, judgments, and expenses (including reasonable attorneys' fees) arising from:

Any Claim by any person or entity claiming through or under Releasor
Releasor's breach of any representation, warranty, or covenant in this Release
Failure to satisfy any lien, subrogation claim, or reimbursement obligation (including Medicare conditional payments)
Any tax liability arising from the Settlement Amount

12.2. The indemnification obligations survive the execution and delivery of this Release.

13. CONFIDENTIALITY

☐ Confidentiality Required.

13.1. The terms of this Release, including the Settlement Amount, are confidential. Neither party shall disclose the terms to any third party except:

Legal and tax advisors
Immediate family members (with admonition of confidentiality)
As required by law, regulation, or court order
As necessary to enforce the terms of this Release
As required for tax reporting purposes
To Medicare, Medicaid, or other government agencies as required

13.2. Breach of confidentiality shall entitle the non-breaching party to liquidated damages of $[________________________________] per occurrence, or actual damages, whichever is greater.

☐ No Confidentiality Restriction. The terms of this Release are not confidential.

14. NON-DISPARAGEMENT

☐ Non-Disparagement Required.

14.1. Neither party shall make disparaging, defamatory, or derogatory statements about the other party or any Released Party in connection with the Incident or this Release.

☐ No Non-Disparagement Restriction.

15. TAX IMPLICATIONS

15.1. Releasor acknowledges that portions of the Settlement Amount may be subject to federal and state income tax. The parties make no representations regarding the tax treatment of the Settlement Amount.

15.2. Releasor is solely responsible for determining and paying any tax obligations arising from the Settlement Amount.

15.3. To the extent required by law, Releasee or Releasee's insurer will issue IRS Form 1099 reflecting payments made.

15.4. Releasor is advised to consult with a tax professional regarding the tax implications of this settlement.

16. GENERAL PROVISIONS

16.1. Governing Law. This Release is governed by the laws of the Commonwealth of Pennsylvania, without regard to conflict-of-laws principles.

16.2. Forum Selection. Any dispute arising from this Release shall be resolved in the Courts of Common Pleas, [________________________________] County, Pennsylvania, or the United States District Court for the [________________________________] District of Pennsylvania.

16.3. Entire Agreement. This Release, together with any exhibits, constitutes the entire agreement between the parties regarding the subject matter and supersedes all prior or contemporaneous agreements, understandings, or representations.

16.4. Amendment. This Release may be amended only by a written instrument signed by both parties.

16.5. Severability. If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

16.6. Waiver. No waiver of any right shall be effective unless in writing signed by the waiving party.

16.7. Successors and Assigns. This Release is binding upon and inures to the benefit of the parties and their respective heirs, executors, administrators, successors, and assigns.

16.8. Counterparts. This Release may be executed in counterparts, each of which is an original. Signatures by facsimile, PDF, or electronic signature shall constitute original signatures.

16.9. Headings. Section headings are for convenience only and do not affect interpretation.

16.10. Construction. This Release shall be construed as a whole and shall not be construed against the drafter.

17. EXECUTION BLOCK

IN WITNESS WHEREOF, the parties have executed this General Release of All Claims as of the Effective Date.

RELEASOR

I have read this Release, understand its terms and consequences, and execute it voluntarily as my free act and deed, intending to be legally bound.

Signature: _____________________________________________