Settlement Authorization Form

SETTLEMENT AUTHORIZATION FORM

This Settlement Authorization Form is executed as of Effective Date: by and between Claimant Name: (referred to herein as "Claimant") and Respondent/Payor Name: (referred to herein as "Respondent"). This Form sets forth the Claimant's authorization and instructions with respect to the settlement of the claims identified below.

RECITALS

WHEREAS, Claimant asserts certain claims against Respondent arising out of the incident dated Incident Date: identified by Claim/Case Number: ; and

WHEREAS, the parties have negotiated terms of settlement and intend to effectuate a full and final resolution of all claims, demands, and causes of action arising from the matters described above; and

WHEREAS, Claimant desires to authorize specified persons and agents to accept payment, execute releases, and take such actions as are necessary to implement the settlement on the terms set forth in this Form.

NOW, THEREFORE

In consideration of the mutual covenants set forth below and other good and valuable consideration, receipt of which is hereby acknowledged, the parties agree as follows:

1. SETTLEMENT TERMS

1.1 Settlement Amount. Respondent shall pay Gross Settlement Amount: $ in full and final settlement of the claims described in the recitals. Payment shall be made in accordance with the Distribution of Funds clause below.

1.2 Settlement Date. The parties agree that the settlement shall be effective on Settlement Date: , subject to receipt and clearance of funds.

2. AUTHORIZATION AND RELEASE

2.1 Authorization to Execute Instruments. Claimant hereby irrevocably authorizes and directs Respondent, or Claimant's counsel where applicable, to prepare, present, and execute all releases, waivers, receipts, and other instruments necessary to effectuate the settlement and to obtain and retain payment. Claimant agrees to execute such documents upon request and to cooperate fully in implementing the settlement.

2.2 Release. Upon receipt and clearance of payment in full as provided herein, Claimant shall execute a full general release in favor of Respondent and its officers, directors, employees, agents, insurers and assigns, releasing and forever discharging them from all claims, causes of action, liabilities and demands known or unknown arising out of the matters described in the recitals.

3. DISTRIBUTION OF FUNDS

3.1 Allocation. Settlement distribution shall be as follows: Attorney Fees: $; Medical/Lien Holdbacks: $; Net to Claimant: $. These allocations are final for purposes of this settlement unless otherwise agreed in writing.

3.2 Authority to Endorse and Receive Payment. Claimant authorizes Respondent to issue settlement payment to Payee Name: and directs that such payment constitutes full satisfaction of the Claimant's claims upon receipt and clearance. If payment is issued jointly, Claimant authorizes any designated agent to endorse on Claimant’s behalf.

4. LIENS, SUBROGATION AND THIRD-PARTY CLAIMS

4.1 Lien Satisfaction. Claimant represents that Claimant has disclosed all known liens, subrogation interests, or third-party claims against the settlement proceeds. Claimant authorizes the use of settlement funds to satisfy valid liens, and agrees to cooperate to obtain lien releases or to allocate funds to satisfy such obligations.

4.2 Indemnity. Claimant agrees to indemnify and hold harmless Respondent from any claims arising from undisclosed liens or claimant obligations to third parties that are not satisfied from the settlement proceeds, except to the extent such claims arise from Respondent's intentional misconduct.

5. REPRESENTATIONS AND WARRANTIES

Each party represents and warrants that it has full authority to enter into this Form, that the person signing on its behalf is duly authorized, and that no further approvals are required to effect the settlement except as expressly set forth herein.

6. TAX TREATMENT

Unless otherwise agreed in writing, each party is responsible for its own tax reporting and liabilities that may arise from the settlement proceeds. Respondent shall not be responsible for withholding or reporting taxes on behalf of Claimant, except to the extent required by applicable law.

7. CONFIDENTIALITY

The parties agree that the terms and existence of the settlement shall be treated as confidential and shall not be disclosed to any third party except as required by law or as necessary to implement the settlement, including to tax advisors, counsel, and lienholders who must be informed to effect distribution.

8. NOTICES

All notices required or permitted under this Form shall be in writing and shall be deemed delivered when delivered personally, by nationally recognized overnight courier, or by certified mail to the addresses provided above or to such other address as a party designates in writing.

9. AMENDMENTS; WAIVER; COUNTERPARTS

This Form may be amended only by a written instrument executed by both parties. No waiver of any provision shall be effective unless in writing and signed by the party waiving the provision. This Form may be executed in counterparts, each of which shall be deemed an original, and delivered by electronic transmission of a signed copy.

10. GOVERNING LAW; SEVERABILITY; ENTIRE AGREEMENT

This Form shall be governed by and construed in accordance with the laws of the State of Governing Law State: without regard to its conflict of laws principles. If any provision of this Form is held invalid or unenforceable, the remaining provisions shall remain in full force and effect. This Form constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations and agreements.

11. MISCELLANEOUS PROVISIONS

11.1 Authority to Execute. Each person executing this Form on behalf of a party represents and warrants that the signatory has full authority to bind the party they purport to represent.

11.2 Cooperation. The parties shall cooperate and execute any additional documents reasonably necessary to effectuate the terms of this Form.

ADDITIONAL INSTRUCTIONS / SPECIAL TERMS

CERTIFICATIONS

Claimant certifies that Claimant has read this Form, understands its terms, and acknowledges that by signing below Claimant authorizes the settlement and release described herein and represents that all information provided is true and complete to the best of Claimant's knowledge.

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