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RELEASE AND SETTLEMENT AGREEMENT Release In consideration of the delivery of a check, draft or other negotiable instrument to the undersigned in the sum of Sixteen Thousand Dollars ($16,000.00), receipt of which is hereby acknowledged, the undersigned does hereby release and forever discharge City of Everett and its agents, employees, assigns and insurers from all claims, demands, damages, actions or causes of action known as well as unknown and unanticipated whether on account of damage or loss to property, bodily injury, loss of consortium, death or otherwise arising out of or resulting from an accident which occurred on or about October 23, 2016. This Release includes but is not limited to the specific release and waiver of any private right of action the undersigned may have against the above-named released parties under 42 USC §1395y(b)(3)(A). Claims Against the Proceeds, Indemnity, and Hold Harmless The undersigned agrees to satisfy all liens, subrogation claims, or other rights or interests arising from the accident pertaining directly to the undersigned and asserted in or against the above- stated settlement proceeds that pertain directly to the undersigned and, further, to indemnify City of Everett's insurance company, and to hold those parties harmless from any and all such liens, subrogation interests or other rights arising from this accident including any claims for loss of consortium or other derivative actions. This includes but is not limited to any and all liens of workers compensation insurance, hospital liens, ambulance liens, attorney liens, unpaid medical bills, insurer's claims for reimbursement of Personal Injury Protection benefits paid to the undersigned, and the liens of any public agencies providing medical or other assistance including but not limited to Medicaid, Medicare, The Veterans Administration, Adult and Family Services, or other welfare. Medicare's Interests With regard to Medicare, it is the undersigned's intent to adequately consider and protect Medicare's interests. It is not the purpose of this Settlement Agreement to shift responsibility of medical care in this matter to the Medicare program. Instead, this Settlement Agreement is intended to resolve a dispute between the undersigned and the released parties. The undersigned acknowledges and represents that Medicare has no interests in this settlement. Specifically, the undersigned acknowledges and represents that the undersigned is not a Medicare beneficiary, that Medicare has made no payments for medical treatments in connection with the injuries arising from this accident, that the undersigned does not anticipate becoming a Medicare beneficiary within the next 30 months, and that the undersigned does not anticipate incurring any further medical treatments related to the injuries arising from the accident involved in this settlement. Covenant Not to Sue To the extent the undersigned intends to pursue the claim against any other individuals or entities, this document shall be considered as a "covenant not to sue" given in "good faith" sufficient to provide the above-mentioned released parties the full protection and discharge from liability to any other potential tortfeasors. RELEASE & SETTLEMENT AGREEMENT- 1 .tnr7o6o85/OO$ /009784 t t vi