Personal Injury Settlement Sheet Template: Payouts & Liens

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]

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]

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]

Type of Coverage: [Type]

Settlement Source 3:

[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 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]

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]

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]

Name: [Name]

Type: [Type]

Adjusted / Negotiated Amount: $[Amount]

Provider / Lienholder 3:

[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.

1. Total Gross Settlement Amount:

   $[Total Gross Settlement]

2. Less Attorney’s Fees:

   – $[Attorney Fee Amount]

3. Less Case Costs / Expenses:

   – $[Total Costs]

4. Less Medical / Lien Payments:

   – $[Total Medical/Lien Payments]

5. Less Other Deductions (if any):

   – $[Total 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]

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.

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.]