Fill and Sign the Disputed Claim Form

Agreement for Accord and Satisfaction of a Disputed Claim (i.e., Personal and Property Damages) for Negligence FULL AND COMPLETE RELEASE WHEREAS, on or about ___________________ (Day, Month, Year), ___________________ ( ฀Plaintiff ฀), an adult resident citizen of ___________________ (County, State) was involved in an automobile accident on ___________________ in ___________________ (County, State) when the car he was driving collided with a vehicle driven by ___________________ ("Defendant"); and WHEREAS, Plaintiff has made a claim for alleged damages resulting from the ac cident against Defendant; and WHEREAS, a dispute subsequently arose between Plaintiff and Defendant regarding liability for the accident and any damages to Plaintiff; and WHEREAS, Defendant, while denying that he is, or was, liable to Plaintiff, or to anyone else, for any amount whatsoever as a result of the aforesaid accident, and further denying that he is, or was, liable to Plaintiff for any alleged damages resulting from the aforesaid accident, or which could arise out of the aforesaid accident, has, nevertheless, offered to pay the sum of ____________________________________ Dollars ($___________________) to Plaintiff upon the condition that he accept said amount as a full and complete compromise a nd settlement of any and all injuries, damages, and other type claims, grievances , demands, actions, or causes of action, of whatever nature, which they have, have had, or may hereafter have, against Defendant and all of his employees, agents, servants, attorneys, successors and assigns, which arise from , or pertain in any manner to, the aforesaid accident, or any injuries or damages, persona l and/or property, resulting therefrom which are being asserted, which could have been asserted, and/or which have been asserted; and WHEREAS, Plaintiff and his wife represent that they are both adults and have agreed to accept the above and foregoing amount upon the above and foregoing conditions; NOW, THEREFORE, for and in consideration of the sum of ____________________________ Dollars ($___________________) cash in hand paid, the receipt and sufficiency of which is hereby acknowledged, we, Plaintiff and wife, jointly and severally, for ourselves, our heirs, administrators, executors and assigns, do hereby release, acquit and forever discharge Defendant, and all of his employees, agents, servants, attorneys, successors and assigns, from any and all losses, injuries, claims, demands, actions, causes of action, payments, costs, expenses, damages, liability, or grievances of any nature whatsoever which we have had, which we may now have, or which we may hereafter have, which in any manner pertain to, relate to, or arise from any personal injury, known and unknown, property damage, known and unknown, or any other loss of any nature whatsoever sustained as a result of the aforesaid vehicular accident which occurred on or about ___________________ (Day, Month, Year) , involving the vehicle driven by Plaintiff and the vehicle driven by Defendant. For the same consideration, Plaintiff and wife, jointly and severally, do hereby agree, understand and acknowledge that this release shall be and constitute a complete a nd total bar to the maintenance of any action or suit, at law or in equity, against Defendant a nd all of his employees, agents, servants, attorneys, successors and assigns, based upon or in any manner pertaining to any losses, injuries, claims, demands, actions, causes of actions, payment s, costs, or expenses, which arise from, or in any manner pertain to, any injury or damage to person or property which may have been sustained as a result of the aforesaid vehicular accident. And for the same consideration, we, the undersigned, Plaintiff and wife, jointly and severally, for ourselves, our heirs, administrators, executors and assigns, do hereby agree to defend, indemnify and hold harmless the aforesaid Defendant and all of his employees, agent s, servants, attorneys, successors and assigns, from any and all costs, expenses, or liability which they may hereafter incur, jointly or severally, as a result of, or in any manner pert aining to, any injuries or damages, of whatsoever kind or nature, sustained by Plaintiff and/or wife, involving the vehicle driven by Plaintiff and the vehicle driven by Defendant on or about ___________________ (Day, Month, Year) in or as a result of said vehicular accident. It is expressly understood and agreed that the amount being paid under the terms of this agreement is in consideration of the settlement of a doubtful claim, and that any an all liability is expressly denied by Defendant, and that the making of this settlement agreement and the payment of said _________________________________ Dollars ($___________________) is not to be construed as an admission of liability on the part of Defendant. Witness our signatures this the ____ day of ___________________, 20____. _____________________________________ _____________________________________ Signatures of Plaintiff and Wife STATE OF COUNTY OF Personally came and appeared before me, the undersigned authority in and for the aforesaid jurisdiction, ___________________________ and wife, ___________________________, who acknowledged that they have this day signed and executed the above and foregoing Full a nd Complete Release for the purposes therein stated, after having first duly read comple tely the same, and after having had the benefit of their attorney's advice and an understanding of all the terms thereof. GIVEN under my hand and seal of office, this the ____ day of ___________________, 20____. ________________________________NOTARY PUBLIC My commission Expires: _____________________ I, ___________________, for and on behalf of ___________________ attorneys for ___________________ and ___________________ have explained to my clients the terms of this Full and Complete Release, and they have represented to me that they ful ly understand the terms thereof and their significance, and have freely and voluntarily signed this Full a nd Complete Release. __________________________________ Signature of Attorney