Fill and Sign the Settle Claim Form

IN THE CHANCERY COURT OF       COUNTY, MISSISSIPPI IN THE MATTER OF       , A MINOR BY       , AS NATURAL FATHER/MOTHER AND NEXT FRIEND OF       , A MINOR II. The Court has jurisdiction over the parties and the subject matter of these proceedings. III.       , a minor, has a contingent and unliquidated claim for personal injuries and damages against       ,       and       Insurance Company on account of an accident which occurred on       . A copy of the Police Accident Report is attached hereto as Exhibit "       ".       , at the time of the accident, was a passenger in a school bus at the time of the accident.       was driving his/her vehicle behind the school bus when he/she collided into the rear of the school bus. The accident occurred in       County, Mississippi. Petitioner would also show unto the Court that the requirement of furnishing security herein is not required by §93 - 13 - 211 of Mississippi Code Annotated (1972) unless this Court shall order same. Petitioner would further show that his/her natural love and affection for the minor child named herein will assure his/her faithful performance as to the disposition of the settlement proceeds for the use and benefit of said child IV.       sustained certain personal injuries as a result of the accident and was taken from the scene of the accident to       for examination.       was examined, but not seriously injured.       has been released from medical care.       has incurred the following expenses in association with his/her medical treatment for her injuries arising out of the accident on       :       $             $       Total $       V.       ,       and       were the named insured on the insurance policy provided by       on the date of the accident. The insurance carrier,       , has offered to pay the total sum of       ($       ) to       , natural father/mother and next friend of       and for the use and benefit of said minor, provided that said sum when paid and received would constitute a full and final accord and satisfaction of any and all claims and causes of action and any present and future known and unknown claims with       , his/her heirs, successors, assigns and personal representatives may now or hereafter have against       ,       ,       , or       in any way arising out of or in connection with the aforesaid accident and all injuries and damages sustained as a result thereof. Should the said settlement be approved by this Court and consummated as proposed,       will further require       , natural father/mother and next friend of       , to execute the original of a Full and Final Release of all claims, a true copy which is attached hereto as Exhibit expenses in association with his/her medical treatment for his/her injuries arising out of the accident on       :       $             $       Total $       V.       ,       , and       were the named insured on the insurance policy provided by       on the date of the accident. The insurance carrier,       , has offered to pay the total sum of       ($       ) to       , natural father/mother and next friend of       , and for the use and benefit of said minor, provided that said sum when paid and received would constitute a full and final accord and satisfaction of any and all claims and causes of action and any present and future known and unknown claims with       , his/her heirs, successors, assigns and personal representatives may now or hereafter have against       ,       ,       and       , in any way arising out of or in connection with the aforesaid accident and all injuries and damages sustained as a result thereof. Should the said settlement be approved by this Court and consummated as proposed,       will further require       , natural father/mother and next friend of       , to execute the original of a Full and Final Release of all claims, a true copy which is attached hereto as Exhibit "       " and incorporated herein by reference as if copied herein in full words and figures. VI. Petitioner represents that       , insurer for       ,       and       is legally obligated to pay sums to the minor as a result of the injuries described about, with said legal liability being disputed and denied. Due to the hazards of litigation inherent in any lawsuit and the unpredictability of a jury verdict under the circumstances in question, the claims of said minor are of a doubtful nature. VII. Petitioner requests that he/she be allowed to accept the amount offered by       in full and final settlement of the claims of the minor child resulting from the above described accident. Petitioner requests that he/she be allowed to make the following disbursements to the following parties in the following amounts out of the settlement funds:       $             $       Total $       Petitioner would show that he/she , on behalf of the minor, has employed       , Esquire, of       , Mississippi, as his/her attorney; that said attorney has advised them, had investigated the aforesaid accident and evaluated the claims of the minor and had negotiated with parties representing       . Petitioner would further show unto the Court that       , Esquire, his/her attorney, is entitled to compensation from the aforesaid settlement amount in the sum of $       for reasonable attorney's fees and the sum of $       for out - of - pocket expenses incurred, for a total payment of $       to said attorney from the aforesaid settlement amounts. Petitioner further requests that he/she be allowed to accept and hold the remainder of the settlement funds in the amount of $       for the use and benefit of said minor without a guardianship, being aware that he/she remains amenable to this Court for the proper disposition of said funds. VIII. The undersigned Petitioner recommends to this Court that the settlement be approved and states that he/she is of the opinion that it is in the best interest and welfare of       , a minor, that said settlement be consummated as set forth hereinabove. WHEREFORE, PREMISES CONSIDERED, Petitioner prays that: 1. This Petition be received and filed, and a full and complete investigation into the facts pertaining to the accident in which       , a minor, was injured be made at an immediate hearing; 2. If upon investigation this Court is satisfied that the proposed offer of settlement is a fair and reasonable offer and that it is in the best interest and welfare of the said minor that the settlement be made, a decree be granted accordingly, approving and authorizing such settlement 3. Petitioner herein be authorized to receive and accept the settlement sum of       ($       ) and out of that amount he/she be authorized, empowered and directed to pay the following:       $             $       Total $       Petitioner be authorized to pay as a reasonable attorney's fee and reimbursement for out - of - pocket expenses in the amount of $       to       , Esquire, from settlement proceeds. Additionally, that he/she be authorized, empowered and directed to receive and hold the remainder of the settlement funds for the use and benefit of said minor without guardianship, being aware that he/she remains amenable to the Court for the proper disposition of said funds; 4. The Court will approve the proposed Release and Indemnity Agreement attached hereto as Exhibit "       " and upon payment and/or tender of said settlement sum to Petitioner that he/she be authorized, empowered and directed to execute in favor of       ,       ,       and       a complete and binding Release and Indemnity Agreement of all claims based upon injuries and damages sustained by       on account of the above described accident in the form of the document attached hereto as Exhibit "       " and no other; 5. Bond, inventory and annual accounting be waived until such further order of this Court; and 6. If mistaken in the relief herein prayed for, then your said Petitioner prays for such other, further and more general relief as appears to a court of equity to be both mete and proper, as in duty bound your Petitioner will ever pray. Respectfully submitted, this the       day of       , 20       . _______________________________________       Attorney for       Of Counsel:                         Telephone:       MSB #       Attorney for