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HomeMy WebLinkAboutCRA-R-23-0060 BackupRELEASE OF ALL CLAIMS THIS INDENTURE WITNESSETH that in consideration of the payment to SANDRA HAPUARACHCHI (DOB: ; SS#: )(the "RELEASOR") of the sum of FIFTY FIVE THOUSAND AND NO/100 DOLLARS ($55,000.00), receipt whereof is hereby acknowledged, I, , for myself and for my heirs, personal representatives and assigns, release and forever discharge the SOUTHEAST OVERTOWN PARK WEST REDEVELOPMENT AGENCY ("CRA"), its current and former departments, officers, agents, servants, and employees, its contractors, lessees, and any other person, firm or corporation charged or chargeable with responsibility or liability, their respective heirs, representatives and assigns (collectively the "RELEASEES"), from any and all claims, demands, causes of action, whether in the nature of subrogation or otherwise, arising from any act or occurrence from the beginning of time through the present, and particularly on account of all personal injury, survival, or death, disability, property damage, costs, loss of services and consortium, expenses, attorney's fees, compensation, deprivation of any kind already sustained or that may hereafter be sustained, including reputation or civil rights, on account of, or in any way growing out of, an incident occurring at the parking lot located at or near 663 N.W. 1st Court, Miami, Florida, on or about June 3rd, 2015, and during which the RELEASOR was allegedly injured (the "incident"), and as a consequence of which suit was filed in the Circuit Court in and for Miami -Dade County, Case No. 2019-008650-CA-01. To procure payment of the said sum, the RELEASOR hereby declares, and covenants as follows: 1. That the RELEASOR is of full age, under no legal disability and is competent to attest to these matters; 2. That the RELEASOR has not been influenced in any manner, or to any extent, in making this Release by any representations or statements regarding damages, or regarding any other matters, by the RELEASEES, or by any person or attorney(s) representing them, or any of them individually, or by anyone employed by them; 3. That the injury, disease or illness, if any, sustained by RELEASOR, as the proximate result of the aforesaid incident, may be permanent, progressive, or not fully known to RELEASOR at this time, and that recovery there from may be uncertain and indefinite, and in making this Release, he relies wholly upon the advice of his attorney, and upon his own individual judgment, belief and knowledge of the nature, extent and duration of said injuries, illness or disease, and all damages arising there from; 4. That RELEASOR has had the benefit of counsel of her own attorney(s), and that RELEASOR fully understands the terms of this Release, and that RELEASOR is making full and final settlement of all claims of every nature and character against the RELEASEES; 5. That there are no unpaid obligations incurred and owing by RELEASOR, to any hospital or medical care provider for services, medicines, medical appliances, rehabilitation, X- rays, or diagnostic tests of any kind, rendered or incurred as a result of the incident described herein; Page 1 of 4 RELEASE OF ALL CLAIMS CASE NO.: 2019-008650-CA-01 6. That there is no outstanding attorney's lien in connection with the sum paid herein to the RELEASOR; 7. That no claim has been made by RELEASOR, against any person, firm or corporation as an alleged employer under the Workers Compensation laws of the State of Florida, any other state, or the federal government, in connection with the said incident which would give rise to a lien against the proceeds of this settlement, which lien has not been satisfied or released by RELEASOR; nor have any medical services of doctors, nurses, hospitals or other institutions of any kind, drugs, medicines, etc., been furnished to RELEASOR by any such employer in connection with the said incident, which would give rise to a lien against the proceeds of this settlement, which lien has not been satisfied or released; 8. That this Release is made to induce the said RELEASEES, and those making payment for, or on behalf of, said RELEASEES, to settle with RELEASOR, and to pay said sum of money to RELEASOR without securing any of the following (which, if they exist, have been fully satisfied or released): a. Any release or satisfaction of lien of any funeral home, hospital or medical care provider in the State of Florida, or any other state or territory of the United States; b. Any release or satisfaction of lien of any hospital of the United States Government, including Veterans Hospitals, Naval Hospitals, or Military Hospitals; c. Any release or satisfaction of lien of any employer, or insurance carrier of any employer, for benefits, services, medical and otherwise, paid by virtue of the Workers' Compensation Law of the State of Florida, any other state or territory of the United States, or the federal government; d. Any release or satisfaction of any lien of any insurance carrier for benefits and services, medical or otherwise, paid by virtue of the Florida Motor Vehicle No -Fault Law, or any other insurance policy, auto, life or otherwise; e. Any release of lien from any attorney; and f. In the event any such lien, or liens, described above not be satisfied, released, or otherwise extinguished, THE RELEASOR SPECIFICALLY UNDERTAKES AND AGREES TO INDEMNIFY, HOLD HARMLESS AND DEFEND the said RELEASEES, from any action or claim asserting such liens against the RELEASEES, including all losses, costs, expenses, judgments and attorney's fees incurred as a result of the assertion thereof: Page 2 of 4 Initials RELEASE OF ALL CLAIMS CASE NO.: 2019-008650-CA-01 9. The RELEASOR further stipulates that she is/not receiving or has/not applied for Medicare or Medicaid benefits. It is not the intent of the RELEASEES to shift the burden to Medicare to pay for the RELEASOR's future medical treatment related to her injury(ies). RELEASOR does hereby indemnify and agrees to hold harmless the RELEASEES and the attorney of the RELEASEES, departments, officers, agents, servants, and employees, of and from any cost, lien, penalties, fees or damages which may arise in connection with any action taken by Medicare or Medicaid as a result of this settlement. The RELEASOR agrees to save, out of the settlement proceeds, settlement monies to cover any and all expected Medicare reimbursable benefits. The RELEASOR is responsible for compliance with all notice and other requirements pursuant to the Medicare Secondary Payer Statute (MSPS) codified at 42 U.S.C. §1395y(b)(2) and any other legislation, rule, statute law or ordinance pertaining to the Medicare or Medicaid payments or claims arising out of this accident or occurrence; 10. That this Release contains the entire agreement between the parties hereto and the terms of this Release are contractual and not a mere recital; 11. That RELEASOR hereby specifically waives, extinguishes and discharges the subrogation rights (as to the RELEASEES only) of any insurance carrier arising under any policy of insurance for benefits paid to RELEASOR, even though RELEASOR may be contractually prohibited from doing so by said policies of insurance; and, should the holder of any subrogation right proceed against any or all of said RELEASEES, RELEASOR SPECIFICALLY UNDERTAKES AND AGREE TO INDEMNIFY, HOLD HARMLESS AND DEFEND the said RELEASEES, from all such claims, demands, etc., including all losses, costs, expenses, judgments and attorney's fees incurred as a result thereof; and 12. RELEASOR hereby agrees that, as a further consideration and inducement, this Release shall apply to all unknown and unanticipated injuries, illnesses, limitations, disabilities, and damages, proximate or remote, resulting from said incident, casualty or event, as well as to those now disclosed. 13. RELEASOR expressly agrees that the terms of this settlement shall remain confidential and not disclosed to third parties and agrees to keep the terms of this release in strict confidence. The RELEASOR, and her attorneys, further agree not to discuss the facts or circumstances of this case with any news media, publications, legal periodicals, newsletters, lawyer networks or case reporting services, or any form of media whatsoever. The consideration for this confidentiality provision is the mutual promises of each party to this Release to keep this matter confidential 14. RELEASOR understands that the RELEASEES admit no liability of any sort by reason of said incident and that said payment and settlement provided for herein in compromise is made to terminate further controversy respecting all claims for damages that RELEASOR has Page 3 of 4 Initials RELEASE OF ALL CLAIMS CASE NO.: 2019-008650-CA-01 heretofore asserted or that RELEASOR, or her personal representative(s), might or could hereafter assert because of the said incident. SIGNED AND SEALED this day of ,20 (CAUTION: READ AND UNDERSTAND THIS DOCUMENT FULLY BEFORE SIGNING) Name: STATE OF FLORIDA ) ss: COUNTY OF MIAMI-DADE ) The foregoing instrument was acknowledged before me this day of , 20 , by , who is personally known to me or who has produced as identification and who did/did not take an oath. My Commission Expires: SIGNATURE PRINT Notary Public State of Florida My Commission Expires: Did Take An Oath Did Not Take An Oath Personally Known Produced I.D., Type of I.D. Produced: Page 4 of 4 Initials