Injury Claim Release Form

INJURY CLAIM RELEASE FORM

This Injury Claim Release Form is made and entered into on this date: by and between Claimant Name: (hereinafter “Claimant”) and Releasee Name: (hereinafter “Releasee”).

RECITALS

WHEREAS, on or about the date of the Incident: , Claimant alleges that Claimant sustained personal injuries arising out of or related to the event described as: (the “Incident”);

WHEREAS, Claimant has asserted or may assert claims, demands, causes of action, or liabilities of any nature whatsoever, whether known or unknown, suspected or unsuspected, in law or in equity, that arise from, relate to, or are connected with the Incident (collectively, the “Claims”); and

WHEREAS, the parties desire to fully and finally resolve, compromise, and settle all Claims without admission of liability and to avoid the expense and uncertainty of litigation.

NOW, THEREFORE

In consideration of the mutual covenants and promises contained herein and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Release: (a) “Released Claims” means all claims, demands, causes of action, suits, liabilities, obligations, losses, costs, and expenses (including attorneys’ fees) whether known or unknown, suspected or unsuspected, that Claimant has or may have against Releasee arising out of or in any way related to the Incident; (b) “Settlement Amount” means the total compensation described in Section 2.

2. CONSIDERATION

In full and final settlement of the Claims, Releasee agrees to pay Claimant the Settlement Amount of $ payable as follows: . Claimant acknowledges that this payment is the entire consideration for this Release.

3. RELEASE

Upon receipt of the Settlement Amount, Claimant, on behalf of Claimant and Claimant’s heirs, executors, administrators, successors and assigns, fully and forever releases and discharges Releasee and its officers, directors, employees, agents, insurers, successors and assigns from and against any and all Released Claims arising from or related to the Incident, including but not limited to claims for personal injury, emotional distress, property damage, medical expenses, lost wages, or any other damages.

4. NO ADMISSION OF LIABILITY

The parties expressly acknowledge and agree that this Release and the payments made hereunder are for the purpose of compromise and settlement only and shall not be construed as an admission of liability, fault, or wrongdoing by Releasee, all of which are expressly denied.

5. REPRESENTATIONS AND WARRANTIES

Claimant represents and warrants that Claimant has the sole authority to compromise the Claims, that Claimant has not assigned or transferred any interest in the Claims to any third party, and that Claimant has provided true and complete information concerning the Incident to the best of Claimant’s knowledge. Claimant further represents that Claimant has consulted with, or had the opportunity to consult with, legal counsel and medical providers regarding the Incident and the effect of this Release.

Claimant acknowledges receipt of medical care from the following providers:

6. COVENANT NOT TO SUE

Claimant covenants and agrees that Claimant will not institute, commence, or prosecute any action, suit, or proceeding in any forum against Releasee relating to any Released Claims. In the event Claimant breaches this covenant, Claimant shall be responsible for all costs, attorneys’ fees, and damages incurred by Releasee arising from such breach.

7. INDEMNIFICATION

Claimant agrees to indemnify, defend and hold harmless Releasee from and against any and all claims, liabilities, losses, damages, costs and expenses (including attorneys’ fees) arising out of any breach of Claimant’s representations and warranties set forth herein or any claim by a third party that is inconsistent with the releases and covenants made by Claimant in this Release.

8. TAXES

Each party shall be responsible for its own tax reporting and tax liability arising from the Settlement Amount. Claimant acknowledges that Releasee is not providing tax advice and that Claimant is solely responsible for determining any tax consequences associated with the settlement.

9. NOTICES

All notices required or permitted under this Release shall be in writing and shall be delivered to the addresses set forth above by certified mail, return receipt requested, or by other commercially reasonable means.

10. REMEDIES AND ENFORCEMENT

The parties agree that a breach of this Release would cause irreparable harm and that the non-breaching party shall be entitled to injunctive relief and specific performance in addition to any other available remedies at law or in equity. The prevailing party in any action to enforce this Release shall be entitled to recover its reasonable attorneys’ fees and costs.

11. MISCELLANEOUS

Governing Law: This Release shall be governed by and construed in accordance with the laws of the State of without regard to conflict of law principles.

Entire Agreement: This Release constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, negotiations, and understandings, whether written or oral.

Severability: If any provision of this Release is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect, and the parties shall negotiate in good faith a substitute, valid provision that most nearly effects the parties’ intent.

Amendments; Waiver; Counterparts: This Release may be amended only by a written instrument signed by both parties. No waiver of any provision hereof shall be effective unless in writing and signed by the party against whom enforcement is sought. This Release may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

12. ACKNOWLEDGMENTS

Claimant acknowledges that Claimant has read this Release, fully understands its terms, and enters into it knowingly, voluntarily, and without coercion. Claimant further acknowledges that Claimant has had an opportunity to consult with independent legal counsel of Claimant’s choice.

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