Legal Waiver Questionnaire

LEGAL WAIVER QUESTIONNAIRE

This Legal Waiver Questionnaire (the "Questionnaire") is made and entered into on this day: day of , by and between Releasor Name: , and Releasee Name: .

Releasor hereby completes this Questionnaire to disclose facts and circumstances relating to claims, incidents, or causes of action for which Releasor may be asked to waive legal rights, and Releasee will rely upon the disclosures, representations, and certifications contained herein in determining whether a waiver, release, or settlement is appropriate.

RECITALS

WHEREAS, Releasor asserts that certain facts, injuries, events, or potential claims may exist or have arisen against Releasee; and

WHEREAS, Releasee requires a complete and accurate disclosure of material facts and circumstances and certain acknowledgements and certifications from Releasor prior to execution of any waiver, release, or settlement agreement; and

WHEREAS, the parties wish to record in writing the factual disclosures, representations, and acknowledgements of Releasor as a precondition to any waiver or release of legal rights.

NOW, THEREFORE, in consideration of the mutual covenants and the representations set forth below, and for 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 Questionnaire, the following defined terms apply: "Claim" means any demand, cause of action, suit, liability, loss, damage, cost, or expense (including attorneys' fees) asserted by or on behalf of Releasor against Releasee. "Incident" means the event or series of events giving rise to the circumstances described by Releasor in Section 2.

2. QUESTIONNAIRE RESPONSES AND MATERIAL FACTS

2.1 Incident Description. Describe the facts and circumstances giving rise to the Claim or potential Claim, including all material events, witnesses, and conduct by any party:

2.2 Date of Incident:

2.3 Location of Incident:

2.4 Injuries or Damages Sustained (check all that apply):

None reported Minor injuries (treated without hospitalization) Serious injuries (required hospitalization or surgery)

2.5 Medical Treatment Provided (identify providers, dates, and descriptions of treatment):

2.6 Legal Advice and Representation:

Has Releasor consulted with an attorney about the Incident? Yes No

If yes, identify attorney or firm:

2.7 Prior or Related Claims. Has Releasor previously filed any claim, suit, notice, or demand arising from the same facts? Yes No

If yes, provide details and current status:

2.8 Existing Waivers or Releases. Has Releasor executed any waiver, release, or settlement related to the Incident? Yes No

If yes, describe parties, dates, and material terms:

3. REPRESENTATIONS AND WARRANTIES

Releasor represents and warrants to Releasee that: (a) all information provided in this Questionnaire is true, accurate, and complete to the best of Releasor's knowledge; (b) Releasor has disclosed all material facts known to Releasor that could bear on the existence, scope, or value of any Claim; (c) Releasor has not intentionally omitted any information that would be material to Releasee's decision to accept or reject a waiver or release; and (d) Releasor executes any subsequent waiver or release only after careful review and with full knowledge of the facts disclosed herein.

4. ACKNOWLEDGEMENT OF RISKS AND VOLUNTARY NATURE

Releasor acknowledges that an enforceable waiver or release may require Releasor to relinquish certain legal rights, including the right to pursue claims in court. Releasor further acknowledges that execution of any waiver or release is voluntary, that Releasor has had the opportunity to seek legal counsel, and that Releasee may rely on the representations and certifications contained in this Questionnaire in negotiating or preparing any waiver, release, or settlement document.

5. INDEMNIFICATION

Releasor agrees to indemnify, defend, and hold harmless Releasee and its officers, directors, agents, employees, successors and assigns from and against any and all claims, liabilities, damages, losses, costs and expenses (including reasonable attorneys' fees) arising out of or relating to any misrepresentation, omission, or breach of the representations contained in this Questionnaire.

6. CONFIDENTIALITY

Unless otherwise required by law or court order, Releasee and Releasor agree that the information provided in this Questionnaire shall be treated as confidential and disclosed only to those employees, counsel, or insurers who have a need to know in connection with evaluation, negotiation, or defense of potential claims.

7. NOTICES

Any notice required or permitted under this Questionnaire shall be in writing and delivered to the addresses below by hand, certified mail, or other nationally recognized courier service. Notice shall be effective upon receipt.

8. AMENDMENT; WAIVER; COUNTERPARTS

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

9. GOVERNING LAW; SEVERABILITY; ENTIRE AGREEMENT

This Questionnaire shall be governed by and construed in accordance with the laws of the jurisdiction in which the Incident occurred, without regard to conflict of laws principles. If any provision of this Questionnaire is held invalid or unenforceable, the remaining provisions shall continue in full force and effect. This Questionnaire constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes any prior oral or written statements or understandings relating to the matters set forth herein.

10. CERTIFICATION

By signing below, Releasor certifies under penalty of perjury that the foregoing answers and statements are true, correct, and complete to the best of Releasor's knowledge and belief, and that Releasor understands that Releasee may rely upon the statements contained in this Questionnaire in deciding whether to accept a waiver, release, or settlement.

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