Tort Election Form

TORT ELECTION FORM

This Tort Election Form is entered into between Claimant Name: (hereinafter "Claimant") and Respondent / Carrier Name: (hereinafter "Respondent"), effective as of .

RECITALS

WHEREAS, Claimant alleges a personal injury arising from an incident occurring on or about (the "Incident"), identified in Respondent's records as Claim Number: ; and

WHEREAS, the Incident may give rise to a cause of action in tort against one or more third-party tortfeasors, including: ; and

WHEREAS, Claimant desires to elect the tort remedy and to set forth the terms on which Claimant will pursue third-party recovery and Respondent will assert or preserve subrogation or lien rights.

NOW THEREFORE, in consideration of the mutual covenants set forth below, the parties agree as follows:

1. ELECTION

Claimant hereby elects (select one or more as applicable):

Claimant elects to pursue a third-party tort action against the identified tortfeasor(s) for damages arising from the Incident. Claimant elects to preserve the right to workers' compensation benefits while pursuing third-party tort recovery, subject to Respondent's lien and subrogation rights as set forth herein.

2. ASSIGNMENT, LIEN, AND SUBROGATION

To the extent allowed by applicable law, Claimant assigns to Respondent all rights to recover from any third party for losses attributable to the Incident, including but not limited to claims for medical expenses, lost wages, and other economic damages, up to the amount of medical and indemnity payments advanced or paid by Respondent (the "Lien Amount"). Claimant acknowledges Respondent's lien and subrogation interest for the Lien Amount and agrees that recovered proceeds shall be applied in the following order: (a) reasonable and documented attorneys' fees and court-awarded costs incurred in obtaining recovery; (b) reimbursement to Respondent for the full Lien Amount; (c) any remaining balance to Claimant, less amounts otherwise agreed in writing.

Estimated Lien Amount (if known):

3. COOPERATION AND LITIGATION

Claimant shall reasonably cooperate with Respondent's efforts to pursue recovery from third parties, including providing truthful statements, executing documents reasonably necessary to effectuate subrogation or assignment, and making counsel available for depositions and trial. Claimant agrees not to enter into any settlement, covenant not to sue, or release with any third-party defendant that would adversely affect Respondent's rights without providing Respondent at least days' prior written notice and obtaining Respondent's written consent.

4. ATTORNEYS' FEES AND COSTS

Any attorneys' fees and litigation costs incurred in pursuing third-party recovery shall be paid from gross recovery. Unless otherwise agreed in writing, attorneys' fees shall be calculated pursuant to the fee agreement between Claimant and Claimant's counsel. If Respondent intervenes or participates in the litigation to protect its lien, reasonable attorneys' fees and costs incurred by Respondent in procuring recovery shall be deducted prior to satisfaction of the Lien Amount.

5. WAIVER; LIMITED RELEASE

Claimant acknowledges that by executing this Form, Claimant does not release third parties unless and until Claimant executes a separate settlement agreement. Claimant further acknowledges that, upon recovery and application of proceeds as set forth herein, Claimant's recovery rights against third parties may be reduced by the Lien Amount. Claimant expressly waives any claim for double recovery to the extent recovery would duplicate amounts already paid by Respondent.

6. NOTICES

All notices under this Form shall be in writing and delivered to the addresses below by personal delivery, certified mail (return receipt requested), or courier service. Notice is effective upon delivery or refusal of delivery.

7. REPRESENTATIONS AND WARRANTIES

Claimant represents and warrants that (a) Claimant is the true and lawful owner of any claim or cause of action asserted against third parties arising from the Incident; (b) Claimant has not previously assigned, pledged or compromised any rights to such claims except as disclosed in writing to Respondent; and (c) all information provided to Respondent in connection with this Election is true and complete to the best of Claimant's knowledge.

8. CONFIDENTIALITY

Unless otherwise required by law or court order, the parties agree to keep the terms of any settlement and the specifics of Respondent's lien and recovery confidential, except as necessary to effectuate collection or enforcement or as required to obtain judicial approval.

9. GOVERNING LAW; VENUE

This Form shall be governed by and construed in accordance with the laws of the State of . Exclusive venue for any dispute arising under this Form shall be the state or federal courts located in the county where the Incident occurred or as otherwise required by statute.

10. ENTIRE AGREEMENT; SEVERABILITY; AMENDMENTS; WAIVER; COUNTERPARTS

This Form constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior written or oral agreements. If any provision of this Form is held invalid or unenforceable, the remaining provisions shall remain in full force and effect. This Form may be amended only by a writing signed by both parties. No waiver of any breach shall be effective unless in writing and signed by the waiving party. This Form may be executed in counterparts, each of which shall be an original and all of which together shall constitute one instrument.

11. AUTHORITY

Each signatory below represents and warrants that he or she has full authority to execute this Form on behalf of the party for whom they sign and that execution of this Form is a binding obligation of that party.

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