Legal Slip and Fall Liens Form

Legal Slip and Fall Liens Form

This Legal Slip and Fall Lien Agreement (the "Agreement") is made effective as of by and between Claimant Name: , whose address is (hereinafter "Claimant"), and Property Owner Name: , whose address is (hereinafter "Owner").

Recitals

WHEREAS, on or about , Claimant sustained injuries arising from a slip and fall incident at or on the real property commonly described as (the "Subject Property"); and

WHEREAS, Claimant has incurred or will incur medical, rehabilitative, and related expenses for treatment of injuries caused by the incident, and certain providers may assert liens against recovery or the Subject Property for unpaid charges; and

WHEREAS, the parties desire to set forth their agreement regarding the assertion, recording, priority, enforcement, and release of any lien(s) arising from the slip and fall incident.

NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the parties agree as follows:

1. Definitions

For purposes of this Agreement: "Claim" means any cause of action, demand, or claim for damages, medical expenses, property damage, or other losses arising from the slip and fall incident identified above. "Lien" means any security interest, charging order, or claim asserted by a provider, attorney, or claimant against proceeds of a recovery or against the Subject Property in respect of services rendered or costs incurred in connection with the Claim.

2. Claim Description and Itemized Charges

Total asserted lien amount (inclusive of interest and allowable fees): $

3. Grant of Lien — Limited and Conditional

Claimant asserts and, to the extent authorized under applicable law, grants a lien against any recovery proceeds obtained from Owner or through Owner's insurer, and reserves the right to record a lien against the Subject Property to secure payment of the Total asserted lien amount and related charges as set forth herein. Any recording of a lien shall be subject to the priority of pre-existing recorded mortgages and liens of record.

4. Consideration; Recording; Enforcement

In consideration of Owner's acknowledgement of the Claim and the parties' mutual promises herein, Claimant may, after providing the notices required by Section 8, record such lien in the appropriate land records. Recording and enforcement actions taken by Claimant shall be strictly limited to amounts actually owed to Claimant or to listed providers and shall comply with statutory requirements governing liens. Claimant shall provide Owner at the time of recording with a written statement of amounts claimed and provider identity.

5. Representations and Warranties

Claimant represents and warrants that: (a) Claimant has the legal right to assert the lien(s) described herein for services rendered; (b) to the best of Claimant's knowledge the amounts set forth in Itemized providers and unpaid amounts are accurate and not duplicative of amounts previously released or paid; and (c) no portion of the amounts claimed has been previously released except as fully disclosed in writing to Owner.

6. Notice; Opportunity to Cure

Prior to recording a lien, Claimant shall serve written notice of intent to record on Owner at the Notices address set forth below and allow Owner thirty (30) days to review and, if appropriate, cure outstanding charges or to notify Claimant of disputed amounts. Failure by Owner to timely respond shall not bar Claimant from recording a lien, but Claimant must attach a copy of the notice and proof of mailing/receipt to any recorded instrument.

7. Priority; Subordination

Any lien recorded pursuant to this Agreement shall be subject to existing recorded encumbrances having priority over the date of recordation. Claimant and Owner may, by written agreement, negotiate subordination of the lien to subsequent financing; absent such written subordination the lien shall have the priority set by date of recording.

8. Release and Satisfaction

Upon payment in full of the secured amounts, Claimant shall execute and deliver a written release and satisfaction of lien within ten (10) business days. If Claimant fails to deliver a required release following receipt of full payment, Claimant shall be responsible for any costs and reasonable attorneys' fees incurred by Owner to obtain release.

9. Costs; Attorneys' Fees

If either party brings an action to enforce this Agreement or to challenge the validity or priority of a lien, the prevailing party shall be entitled to recover reasonable attorneys' fees, costs, and expenses in addition to any other relief awarded by the tribunal.

10. Notices

All notices required or permitted under this Agreement shall be in writing and delivered by hand, nationally recognized overnight courier, or certified mail, return receipt requested, to the addresses below (or such other address as either party designates by notice):

11. Governing Law; Venue

This Agreement shall be governed by and construed in accordance with the laws of the state where the Subject Property is located. Any action arising out of or relating to this Agreement shall be brought exclusively in state or federal courts having jurisdiction where the Subject Property is situated.

12. 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 negotiations, understandings, and agreements. If any provision of this Agreement is determined to be invalid, illegal, or unenforceable, the remaining provisions shall remain in full force and effect.

13. Amendment; Waiver; Counterparts

This Agreement may be amended only by a written instrument executed by both parties. No waiver of any breach shall be effective unless in writing and signed by the party to be charged. This Agreement may be executed in counterparts, each of which shall be deemed an original but all of which together shall constitute one and the same instrument.

14. Acknowledgement

Each party acknowledges that they have had the opportunity to consult with legal counsel, have read and understood this Agreement, and that each party signs this document voluntarily and with full knowledge of its legal consequences.

Additional Elections and Declarations

Lien type(s) asserted (check all that apply):

Medical provider lien Rehabilitation/treatment provider lien Attorney's lien for recovery costs/fees Other (specify below)

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