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Personal Injury Settlement Sheet Template
Clearly show how a personal injury settlement is calculated from gross recovery to the client’s final net amount.
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Personal Injury Settlement Sheet Template
[Law Firm Name or Organization]
[Street Address]
[City, State/Province, ZIP/Postal Code]
Phone: [Phone Number]
Email: [Email Address]
1. Case and Client Information
Client Name: [Full Name]
File / Matter Number: [Internal Reference Number]
Type of Case (check or describe):
Motor vehicle accident (may include DUI-related)
Slip-and-fall / premises
Workplace / job-related accident
Dog bite / animal incident
Other personal injury: [Describe]
Date of Incident: [MM/DD/YYYY]
Location of Incident (City, State/Province): [Location]
Opposing Party / Insured: [Name]
Primary Insurance Carrier: [Name]
2. Settlement Overview
Settlement Date (or Proposed Date): [MM/DD/YYYY]
Total Gross Settlement / Judgment Amount (all sources combined):
$[Total Gross Settlement]
Description of Settlement (brief):
[Example: “Policy limits settlement of third-party liability claim,” “Combined settlement from liability and UM carriers,” etc.]
3. Settlement Sources (By Carrier or Defendant)
List each settlement source separately. Add more items as needed.
Settlement Source 1:
Carrier / Defendant Name: [Name]
Type of Coverage (liability, UM/UIM, MedPay, PIP, etc.): [Type]
Claim or Policy Number: [Number]
Gross Settlement Amount from This Source: $[Amount]
Settlement Source 2:
Carrier / Defendant Name: [Name]
Type of Coverage: [Type]
Claim or Policy Number: [Number]
Gross Settlement Amount from This Source: $[Amount]
Settlement Source 3:
Carrier / Defendant Name: [Name]
Type of Coverage: [Type]
Claim or Policy Number: [Number]
Gross Settlement Amount from This Source: $[Amount]
[Add additional settlement sources as needed.]
4. Attorney’s Fees
Fee Arrangement:
Contingency fee based on gross recovery
Contingency fee based on net recovery after certain deductions
Hybrid or other arrangement: [Describe]
Contingency Fee Percentage(s):
Percentage Applied: [__]%
Fee Calculation (example if based on gross settlement):
Gross Settlement Amount: $[Total Gross Settlement]
Multiplied by Contingency Percentage: [__]%
Attorney’s Fee: $[Attorney Fee Amount]
5. Case Costs and Expenses
List all case-related costs and expenses to be reimbursed from the settlement (court fees, records, experts, etc.).
Cost Item 1: [Description, e.g., “Court filing fee,” “Medical records,” “Investigator”]
Amount: $[Amount]
Cost Item 2: [Description]
Amount: $[Amount]
Cost Item 3: [Description]
Amount: $[Amount]
[Add additional cost items as needed.]
Total Case Costs / Expenses: $[Total Costs]
6. Medical Bills, Liens, and Reimbursement Obligations
List each provider, lienholder, or payor with a claim on the settlement (hospitals, doctors, health insurers, government programs, etc.).
Provider / Lienholder 1:
Name: [Provider / Lienholder Name]
Type (medical provider, health insurer, government program, workers’ comp, etc.): [Type]
Original Billed Amount: $[Amount]
Adjusted / Negotiated Amount (if applicable): $[Amount]
Amount to Be Paid from Settlement: $[Amount To Pay]
Provider / Lienholder 2:
Name: [Name]
Type: [Type]
Original Billed Amount: $[Amount]
Adjusted / Negotiated Amount: $[Amount]
Amount to Be Paid from Settlement: $[Amount To Pay]
Provider / Lienholder 3:
Name: [Name]
Type: [Type]
Original Billed Amount: $[Amount]
Adjusted / Negotiated Amount: $[Amount]
Amount to Be Paid from Settlement: $[Amount To Pay]
[Add additional providers or lienholders as needed.]
Total Medical / Lien Payments from Settlement: $[Total Medical/Lien Payments]
7. Other Deductions (If Any)
Use this section for any additional deductions or payments from the settlement (for example, litigation loans, unpaid costs not listed above, or other court-ordered amounts).
Other Deduction 1: [Description, e.g., “Litigation funding payoff,” “Court-ordered reimbursement”]
Amount: $[Amount]
Other Deduction 2: [Description]
Amount: $[Amount]
[Add additional deductions as needed.]
Total Other Deductions: $[Total Other Deductions]
8. Net Settlement to Client
Start with the total gross settlement and subtract fees, costs, and other deductions.
Total Gross Settlement Amount:
$[Total Gross Settlement]Less Attorney’s Fees:
– $[Attorney Fee Amount]Less Case Costs / Expenses:
– $[Total Costs]Less Medical / Lien Payments:
– $[Total Medical/Lien Payments]Less Other Deductions (if any):
– $[Total Other Deductions]
Net Settlement Amount Payable to Client:
$[Net Amount to Client]
9. Settlement Notes and Special Terms
Use this section to note any special terms, partial payments, structured settlements, or holdbacks.
Structured settlement or annuity details (if applicable):
[Description of structure, payment schedule, or annuity provider]Funds held in trust or escrow for future payments or disputes:
[Description and amount]Any pending negotiations with lienholders that may change final numbers:
[Description]Tax considerations to be discussed with a tax professional (if any):
[Brief note, if appropriate]
10. Client Review and Authorization
Client Acknowledgment:
I, [Client Full Name], acknowledge that I have reviewed this Personal Injury Settlement Sheet, including the breakdown of the total settlement, attorney’s fees, case costs, medical and lien payments, other deductions, and my net recovery. I understand that:
This settlement sheet is a summary and that I may ask questions about any item listed.
No attorney, law firm, or organization has guaranteed any specific outcome, tax treatment, or future result.
I have had the opportunity to discuss this settlement and distribution with my attorney and may seek additional legal or tax advice if I wish.
By signing below, I authorize the Law Firm to disburse settlement funds according to this Settlement Sheet (subject to any required updates or final lien adjustments).
Client Signature: _______________________________
Client Printed Name: [Client Full Name]
Date: [MM/DD/YYYY]
11. Attorney / Law Firm Confirmation
I, [Attorney Name], on behalf of [Law Firm Name], confirm that this Settlement Sheet reflects the current understanding of the proposed or finalized settlement distribution based on information available at this time. I have reviewed the settlement terms with the Client and answered any questions to the best of my ability.
Attorney Signature: _____________________________
Attorney Printed Name: [Name]
Law Firm Name: [Law Firm Name]
Date: [MM/DD/YYYY]
12. Internal Use (Optional)
Prepared By (Staff Name): [Name]
Date Prepared: [MM/DD/YYYY]
Reviewed and Approved By: [Attorney / Supervisor Name]
Notes:
[Internal notes or checklist items, if needed.]
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Easy-to-understand jargon
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Details
Learn more about
Personal Injury Settlement Sheet Template
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
PERSONAL INJURY SETTLEMENT SHEET TEMPLATE FAQ
What is a personal injury settlement sheet?
A personal injury settlement sheet is a summary that shows how a settlement or judgment is distributed. It usually lists the total gross settlement, attorney’s fees, case costs, medical liens and bills, other deductions, and the final net amount the client will receive. Law firms and insurance claim handlers often use it to explain the settlement numbers in a simple, transparent way.
How is a personal injury settlement calculated?
In many personal injury cases, the gross settlement is the total amount paid by one or more insurers or defendants. From that amount, attorney’s fees (for example, a contingency percentage), case expenses (filing fees, records, experts), and valid liens or unpaid medical bills are deducted. What remains after those deductions is the client’s net settlement or “take-home” amount. Exact rules and priorities can vary by jurisdiction, lien type, and contract.
What should a Personal Injury Settlement Sheet include?
A helpful Personal Injury Settlement Sheet usually includes: basic case and client information; each settlement source (such as liability, MedPay, PIP, or uninsured motorist coverage) with the amount received; the attorney’s fee and how it is calculated; a list of case costs; medical liens and provider balances; any other deductions; and a clear line for the client’s final net recovery. Many firms also include a client acknowledgment and signature section.
Can I use this settlement worksheet for car accidents, slips and falls, or DUI-related injury claims?
Yes. This Personal Injury Settlement Sheet Template is designed to be flexible for motor vehicle accidents (including DUI-related crashes), slip-and-fall and premises cases, workplace incidents, dog bites, and other personal injury matters. You can add or remove sections to match local law, lien rules, insurance coverages, or your firm’s internal practices.
Is a personal injury settlement sheet legal or tax advice?
No. A settlement sheet is a summary of how money from a settlement will be distributed; it is not legal or tax advice by itself. Questions about whether a settlement is fair, how liens must be handled, or whether any part of a recovery is taxable should be discussed directly with a licensed attorney and, where appropriate, a tax professional before signing or accepting funds.
Can AI Lawyer help me prepare a personal injury settlement sheet?
Yes. AI Lawyer can help you turn your settlement numbers, fee terms, costs, and lien information into a clean Personal Injury Settlement Sheet using this template. You still need to provide accurate figures and verify that the breakdown complies with your jurisdiction’s law and your retainer agreement. This template and any AI-generated content are for document organization only and are not legal or tax advice.
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