Insurance Policy Settlement

Insurance Policy Settlement

Insurer Name:    Claimant / Applicant Name:

Parties and Claim Information

Claim Number:    Date of Loss:

Date of Birth:    Contact Phone:

Policy Details

Policy Number:    Policy Type:

Automobile    Homeowners    Liability    Other:

Policy Period From:    To:

Coverage Allocation and Items Settled

Check all coverages to which settlement applies and indicate allocation amount where applicable.

Bodily Injury — Allocation: $

Property Damage — Allocation: $

Uninsured/Underinsured Motorist — Allocation: $

Settlement Terms

Settlement Amount (Total Consideration): $

Payment Method: Check Electronic Transfer Other

Anticipated Payment Date:    Payment Contingencies:

Release, Waiver and Covenant Not to Sue

In consideration of the Settlement Amount described above and other good and valuable consideration, receipt of which is acknowledged, the Claimant hereby irrevocably releases and forever discharges the Insurer, its parent, subsidiaries, affiliates, agents, employees, attorneys, successors and assigns (collectively, Released Parties) from any and all claims, demands, causes of action, liabilities, losses, costs or expenses, whether known or unknown, suspected or unsuspected, that the Claimant has or may have arising out of or in any way related to the claim, the occurrence described in this settlement, the policy referenced above, or any acts, omissions or conduct occurring on or before the Effective Date of this Settlement Agreement. The Claimant covenants and agrees not to institute or maintain any suit or action against the Released Parties for any such matters released herein.

Subrogation, Liens and Third-Party Interests

Claimant acknowledges and warrants that Claimant has disclosed all liens, assignments, or claims of subrogation or reimbursement related to this claim. If any liens or subrogation interests exist, list known holders and amounts below. Claimant authorizes the Insurer to satisfy or negotiate any such liens from the Settlement Amount prior to disbursement.

Exclusions and Reservation of Rights

This Settlement Agreement does not create coverage where none existed under the policy nor does it constitute an admission of liability by the Insurer. Except as expressly set forth in this Agreement, the Insurer reserves all rights, defenses and coverage positions provided by the policy and applicable law.

Representations, Warranties and Indemnity

Claimant represents and warrants that the information provided to the Insurer in connection with the claim and this settlement is complete and accurate to the best of Claimant's knowledge. Claimant agrees to indemnify and hold harmless the Released Parties from any liability arising from any material misrepresentation or undisclosed lien affecting the Settlement Amount.

Tax Treatment

Claimant is solely responsible for any tax liabilities or reporting obligations resulting from receipt of the Settlement Amount unless otherwise agreed in writing. Claimant agrees to consult with Claimant's own tax advisor regarding tax consequences of this settlement.

Confidentiality

Unless otherwise required by law, the Claimant agrees to keep the terms, amounts and consideration of this Agreement confidential and not to disclose such information to third parties except as reasonably required to enforce this Agreement, to obtain accounting or tax advice, or as required by court order.

Confidentiality Waiver: Claimant does not agree to confidentiality

Beneficiary Designation (If Applicable)

Beneficiary Name:

Relationship:    Percentage of Settlement:

Documentation Checklist

The following documents are attached or will be provided as a condition of payment:

Proof of Loss

Medical Records / Bills

Repair Estimates / Invoices

Lien Releases / Assignments (if applicable)

Representations Regarding Counsel

Has claimant retained counsel in connection with this claim? Yes No

Certification and Agreement

I, the Claimant named above, certify under penalty of perjury that I am the person entitled to receive the Settlement Amount or am authorized to accept this Settlement on behalf of such person. I have read this Settlement Agreement in its entirety, I understand its terms, and I voluntarily accept the Settlement Amount in full satisfaction of all claims released herein. I acknowledge that I have had the opportunity to seek independent legal or financial advice prior to signing this Settlement Agreement.

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