Plaintiff Attorney Legal Information CenterBelow is a sample car accident settlement release drafted by AAA Mid-Atlantic and executed by our client before trial in a personal injury car accident lawsuit in Maryland.
These settlement releases is auto tort cases
I acknowledge that I have read and understood the above Notice.
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Releasors/Claimant Signature__________________________
Date
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Releasors/Claimant Signature__________________________
Date
To be executed by, _______________________ and _______________________, hereinafter ”the Releasors”.
The Releasors do hereby acknowledge receipt of payment in the amount of: ______________________ Dollars and __/100 Cents ($ ) made payable to: “_____________________ and Miller & Zois, LLC,” which payment is accepted in full compromise, settlement, and satisfaction of, and as sole consideration for the final release and discharge of all actions, claims, damages, demands, causes of action, or suits of every kind and nature whatsoever, at law or in equity known or unknown, suspected or unsuspected, disclosed and undisclosed, that now exist, or may hereafter accrue against __________________________________ (hereinafter “The Releasees”) and any other person, insurer, principals, agents, employees assigns, representatives, subsidiaries, corporation, or other business entity responsible in any manner or degree for injuries to the person and property of the Releasors, and the treatment thereof, and the consequences flowing therefrom, as a result of the accident or incident which occurred on or about ______________________, at or near the intersection of _____________________________________________, and for which the Releasors claim the Releasees and the above mentioned persons or entities are legally liable in damages which legal liability and damages are disputed and denied.
The Releasors expressly waive and assume the risk of any and all damages which exist as of the effective date of this Release, but which the Releasors do not know or suspect to exist in his/her favor, whether through ignorance, oversight, error, negligence or otherwise, and which may have materially affected the decision to execute this Agreement.
The Releasors understand and acknowledge that the significance and consequence of this waiver is that even if the Releasors should eventually suffer additional damages arising out of the accident or event described above, the Releasors shall not be able to make any claim against Releasees for those damages. Furthermore, Releasors acknowledge and intend these consequences even as to claims for those damages that may now exist and be unknown to Releasors and which, if known, would materially affect Releasors’ decision to execute this Release, regardless of whether Releasors’ lack of knowledge is the result of ignorance, oversight, error, negligence or any other cause.
The Releasors warrant that no promise or inducement has been offered except as herein set forth; that this release is executed without reliance upon any statement or representation by the person or parties released, or their representatives, their physicians or any other person, concerning the nature and extent of the damage and consequential damages, if any, and of legal liability therefor, if any; and that the Releasors are of legal age, legally competent to execute this release and accept full responsibility therefor.
The Releasors hereby agree to defend, indemnify and hold harmless the Releasees and their insurer(s), against any claims, liens, demands, actions, and causes of action asserted by any person, corporation, insurer, governmental entity or other entity seeking reimbursement of funds incurred or paid to or on behalf of the Releasors for any purpose, which payments (including medical services) were necessitated or allegedly caused as a result of the accident or incident described above, that now exist, or may hereafter accrue against the Releasees.
The Releasers represent and warrant, as a further condition of this settlement and release, that the Releasers have provided the Releasees and their insurer(s), all information the Releasers know about any and all Medicare rights to recovery as of the date this release is executed The Releasors agree to reimburse, indemnify and hold harmless each of the Releasees, persons, firms, corporations released herein and their insurer(s), including their agents and assigns, with respect to all known and unknown Medicare rights to recovery related to the accident or event referred to above for which the Federal government may seek repayment, as well as any fine or penalty the Federal government may seek resulting from the sufficiency and/or accuracy of the information the Releasors provided to the parties released and their insurer(s) regarding Medicare rights to recovery known as of this date.
The Releasors further acknowledge, as part of the consideration for this settlement, that the Releasors are liable for medical expense incurred, and the Releasors agree to distribute all funds received as may be necessary to satisfy all past, present, or future medical expenses and worker’s compensation liens incurred as a result of the accident or incident described above.
The Releasors further represent that the Releasors relied upon legal advice of the Releasors’ attorney, who is the attorney of the Releasors’ own choice.
We do declare that we understand that this release is a final release for all claims we may be entitled to because of the accident or incident described above.
For your protection, Maryland law requires the following to appear on this form:
Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
The Releasors/Claimants must complete the section below:
Signed at _______(CITY)_______(STATE)_______(ZIP)_______, this ___ day of ____________________________________, 20__.
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Witness Signature__________________________
Releasor/Claimant Signature
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Witness Print Name__________________________
Releasor/Claimant Print Name
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Witness Address
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Witness Signature__________________________
Releasor/Claimant Signature
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Witness Print Name__________________________
Releasor/Claimant Print Name
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Witness Address
STATE OF MARYLAND COUNTY OF _______________ ss:
On this ____ day of _________________________, 20__, before me, the undersigned officer, perso
nally appeared __________________________, known to me (satisfactorily proven) to be the persons whose names are subscribed to the within instrument and acknowledged that they executed the same for the purposes therein contained.
In witness hereof, I hereunto set my hand and official seal.
__________________________
Notary Public in and for the
State of Maryland
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Name of Notary Public printed
(Notary Seal)My Commission expires: __________________________
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