Legal Accident Release Form

LEGAL ACCIDENT RELEASE FORM

This Legal Accident Release Form ("Agreement") is entered into by and between Releasor: , Releasor Address: and Releasee: , Releasee Address: . The effective date of this Agreement is .

RECITALS

WHEREAS, on or about at or near an accident occurred involving Releasor resulting in injury, damage or loss (the "Accident"); and

WHEREAS, Releasor asserts claims, demands, actions, causes of action, suits, liabilities, and rights to recover damages against Releasee arising out of or related to the Accident; and

WHEREAS, in consideration of the mutual covenants and payment and/or other consideration described below, the parties desire to fully and finally resolve all disputes, claims, and causes of action relating to the Accident without admission of liability.

NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein and other good and valuable consideration, receipt of which is hereby acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Agreement, "Claims" means any and all actions, causes of action, claims, demands, obligations, liabilities, damages, losses, costs, expenses, and attorneys' fees, whether known or unknown, suspected or unsuspected, which Releasor now has, had in the past, or may have in the future arising out of or related to the Accident or the events described in the Recitals. "Released Parties" means Releasee and Releasee's past and present agents, employees, representatives, insurers, successors, assigns, subsidiaries, affiliates, officers, directors, and attorneys.

2. RELEASE AND COVENANT NOT TO SUE

In exchange for the consideration described in Section 3, Releasor, on behalf of Releasor and Releasor's heirs, executors, administrators, agents, insurers, personal representatives, successors, and assigns, hereby remises, releases, discharges, and covenants not to sue the Released Parties from and with respect to any and all Claims arising out of or in any way related to the Accident occurring on or before the effective date of this Agreement. This release applies to Claims whether based in statute, common law, contract, tort, negligence, strict liability, or other legal theory.

3. CONSIDERATION

As full and complete consideration for the promises contained in this Agreement, Releasee shall provide the following to Releasor: Payment in the amount of $ paid as follows: . Releasor acknowledges that such payment and any other agreed consideration is fair, adequate, and is the entire consideration for this release.

4. SCOPE OF RELEASE

The release in Section 2 includes, but is not limited to, bodily injury, property damage, emotional distress, medical expenses, lost wages, loss of consortium, and all other economic and non-economic losses. Releasor acknowledges that Releasor understands and intends to release both known and unknown claims to the fullest extent permitted by law. Types of claims released (select all that apply):

Bodily injury
Property damage
Emotional distress
Other (describe):

5. REPRESENTATIONS AND WARRANTIES

Releasor represents and warrants that Releasor has the full right, power, legal capacity, and authority to enter into this Agreement and to execute this release; that Releasor has not assigned any Claims released by this Agreement to any third party; and that Releasor has not previously released the Released Parties with respect to the Accident. Releasor further represents that Releasor has read and understands the terms of this Agreement and has had the opportunity to consult with legal counsel.

Was Releasor represented by an attorney in negotiating this Agreement? Yes

6. MEDICAL AUTHORIZATION AND LIEN WAIVER

Releasor authorizes any health care provider, insurer, or other claimant to release to Releasee or Releasee's authorized representatives all records, bills, itemizations, and other information relating to treatment for injuries allegedly sustained in the Accident. Releasor acknowledges that payment of the consideration in Section 3 shall satisfy any lien or claim for medical payment or subrogation to the extent permitted by law.

7. INDEMNIFICATION

Releasor agrees to indemnify, defend, and hold harmless the Released Parties from and against any and all Claims, liabilities, costs, and expenses (including reasonable attorneys' fees) resulting from Releasor's breach of this Agreement, Releasor's misrepresentation of facts material to the Accident, or any claim made by a third party arising from facts within the scope of the release provided herein.

8. NO ADMISSION OF LIABILITY

This Agreement, and compliance with it, shall not be construed as an admission of liability by Releasee or any Released Party, and Releasee expressly denies liability. The parties agree that this Agreement reflects a compromise of disputed claims.

9. NOTICES

Any notice required or permitted under this Agreement shall be in writing and shall be delivered personally, sent by certified mail, return receipt requested, or by nationally recognized overnight carrier, addressed to the parties at their addresses set forth in the opening paragraph or to such other address as a party may designate in writing.

10. GOVERNING LAW; VENUE

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to that State's choice-of-law principles. The parties agree that exclusive venue for any dispute arising under this Agreement shall be in the courts located in that state.

11. ENTIRE AGREEMENT; SEVERABILITY

This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, negotiations, representations, and understandings. If any provision of this Agreement is held to be invalid, illegal, or unenforceable for any reason, the remaining provisions shall continue in full force and effect.

12. AMENDMENT; WAIVER; COUNTERPARTS

This Agreement may be amended only by a written instrument executed by both parties. No waiver of any breach shall constitute a waiver of any other or subsequent breach. This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

13. ACKNOWLEDGMENT

Releasor acknowledges and affirms that Releasor has carefully read this Agreement, understands its contents, has had the opportunity to consult with counsel, and is signing freely and voluntarily without duress or undue influence.

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