Personal Injury and Automobile Accident Agreement

PERSONAL INJURY AND AUTOMOBILE ACCIDENT AGREEMENT

This Personal Injury and Automobile Accident Agreement (the "Agreement") is entered into by and between Claimant Name: with address , and Released Party Name: with address .

RECITALS

WHEREAS, on or about the date of , an automobile collision occurred at or near (the "Accident"), allegedly involving the Claimant and the Released Party;

WHEREAS, as a result of the Accident, Claimant has asserted and may assert claims for bodily injury, medical expenses, lost wages, property damage and other damages, and the parties wish to resolve and settle all such claims, disputes and causes of action between them arising out of or related to the Accident; and

WHEREAS, the Released Party and its insurers have expressed a willingness to provide consideration to Claimant to compromise and settle any and all claims in exchange for a full release and covenant not to sue, subject to the terms and conditions set forth herein.

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 Agreement, the following terms shall have the meanings set forth below: "Claim" means any and all claims, demands, causes of action, suits, rights, liabilities, obligations, losses, damages and expenses, known or unknown, suspected or unsuspected, arising out of or in any way connected with the Accident. "Released Parties" means Released Party Name, its insurers, subsidiaries, predecessors, successors, affiliates, agents, employees, attorneys and representatives.

2. SETTLEMENT CONSIDERATION

In full and final settlement of all Claims, the Released Parties shall cause to be paid to Claimant the gross sum of (the "Settlement Amount"), payable as follows:

Payment Method (describe): .

Payment Due Date: . If payment is by check, the Released Party shall issue the check to Claimant and deliver to Claimant or Claimant's counsel at the address specified in this Agreement within ten (10) business days following the Effective Date defined below.

3. RELEASE AND COVENANT NOT TO SUE

Upon receipt of the Settlement Amount as provided herein, Claimant shall, on behalf of Claimant and Claimant's heirs, executors, administrators, successors and assigns, fully and finally release and discharge Released Parties from any and all Claims, whether known or unknown, suspected or unsuspected, foreseen or unforeseen, that Claimant has or may have against Released Parties arising out of or related to the Accident, including but not limited to claims for personal injury, pain and suffering, medical expenses, lost wages, property damage, emotional distress, and any other losses.

Claimant further covenants and agrees not to commence, prosecute or maintain any action, suit or proceeding against Released Parties for any Claim released by this Agreement, provided that this covenant shall not be construed to bar enforcement of this Agreement.

4. REPRESENTATIONS AND WARRANTIES

Claimant represents and warrants that Claimant is the sole owner of the Claims being released, that Claimant has not assigned any interest in such Claims except as disclosed in writing to Released Parties, and that Claimant has the full legal capacity and authority to execute this Agreement and to receive the Settlement Amount. Claimant further represents that Claimant has not filed for bankruptcy related to the Accident.

The Released Party represents that it has full authority to enter into this Agreement on behalf of any insured or principal, and that the execution of this Agreement is not prohibited by any contractual or statutory provision.

5. MEDICAL AUTHORIZATION; MEDICAL RECORDS

Claimant authorizes and directs all medical providers to release to Released Parties and their representatives any and all medical records, bills and related information reasonably necessary to evaluate the Claim. Claimant further acknowledges that Released Parties may rely upon these records in determining the final Settlement Amount and in discharging any liens.

6. LIENS, SUBROGATION AND THIRD-PARTY CLAIMS

Claimant agrees to disclose any and all liens, claims for reimbursement, subrogation interests or third-party claims known to Claimant, including but not limited to health care provider liens, health plan subrogation, automobile medical payments and workers' compensation liens. Claimant shall cooperate with Released Parties to resolve or satisfy such liens from the Settlement Amount. Known lienholders and amounts:

If any portion of the Settlement Amount is required to be paid to satisfy valid liens or subrogation interests, Claimant authorizes Released Parties to satisfy such obligations directly from the Settlement Amount prior to payment to Claimant.

7. ATTORNEYS' FEES AND COSTS

If Claimant is represented by counsel, any attorney's fees and costs shall be the responsibility of Claimant and shall be paid by Claimant's counsel from the Settlement Amount pursuant to a separate contingent fee agreement, except as otherwise agreed in writing. Attorney Name:

Attorney Fee Arrangement (describe):

8. CONFIDENTIALITY

The parties agree that the terms and amount of this settlement shall remain confidential and shall not be disclosed to any third party except as required by law, to obtain legal or tax advice, to enforce the terms of this Agreement, or to government agencies when legally compelled. Notwithstanding the foregoing, disclosure to medical providers, lienholders and insurers for purposes of lien resolution shall not be deemed a breach of this confidentiality provision.

9. INDEMNIFICATION

Claimant shall indemnify and hold harmless Released Parties from and against any liabilities, damages, losses, costs or expenses (including reasonable attorneys' fees) arising from any breach of Claimant's representations and warranties or from any attempt to pursue Claims released by this Agreement.

10. TAX MATTERS

Each party shall be responsible for its own tax obligations arising from receipt of funds under this Agreement. Claimant acknowledges that Released Parties make no representations regarding the tax treatment or consequences of the payments made pursuant to this Agreement and that Claimant should consult with a tax advisor as necessary.

11. NOTICES

All notices, demands or other communications required or permitted under this Agreement shall be in writing and shall be delivered to the addresses set forth in the opening paragraph or to such other address as a party may designate by written notice to the other party.

12. AMENDMENT; WAIVER; COUNTERPARTS

This Agreement may be amended, modified or supplemented only by a written instrument signed by both parties. No waiver of any provision of this Agreement shall be effective unless in writing and signed by the party against whom enforcement is sought. This Agreement 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.

13. GOVERNING LAW; VENUE

This Agreement shall be governed by and construed in accordance with the laws of the State selected by the parties. The parties submit to the exclusive jurisdiction of the state and federal courts located in the agreed venue for the resolution of any disputes arising out of or related to this Agreement. Agreed State:

14. 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 and understandings, whether written or oral. If any provision of this Agreement is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

15. MISCELLANEOUS

The headings in this Agreement are for convenience only and shall not affect its interpretation. Time is of the essence with respect to any dates or deadlines set forth in this Agreement. Each party acknowledges that it has read and understands this Agreement and has had the opportunity to seek independent legal advice.

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