Preview
FILED: ERIE COUNTY CLERK 04/10/2024 12:53 PM INDEX NO. 805128/2024
NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 04/10/2024
Settlement Statement and Consent to Settle
IN RE: Nicholas Campas as PNG of G.C.
(Prepared: 01/24/2024)
Incident Date: 11/20/22
GROSS SETTLEMENT PROCEEDS:
Gross Settlement Proceeds $50,000.00
Less Attorney's Fee (1/3rd per Retainer) $16,666.67
Total $33,333.33
Less Disbursements $400.00
Less Medicare Lien (Pending) $0.00
Less Medicaid Lien (Pending) $0.00
Less Lien $0.00
Total (Pending) $32,933.33
I DO HEREBY AUTHORIZE my attorneys, Cantor; Wolff Nicastro & Hall to endorse, deposit,
and negotiate the applicable settlement draft on my behalf and;
I HAVE RECEIVED AND REVIEWED a copy of the above statement, which is correct and
satisfactory. I acknowledge that a physician, health care provider, health insurance carrier, HMO, PPO or
any other carrier, Medicare or Medicaid, or a hospital may have a claim against the proceeds of this
settlement for services or benefits paid or provided to me or on my behalf.
I acknowledge that, except as
disclosed on this
statement, my attorneys have not negotiated, satisfied or withheld proceeds to satisfy
any lien which may exist. If they have not been paid, I will be solely responsible for payment of same. I
hereby authorize my attorneys to issue checks as set forth above.
I understand that this will be a full and final settlement of all claims against the defendant(s) and
direct Cantor, Wolff, Nicastro & Hall to accept the offer of settlement above and execute the settlement
statement in the manner
described above. I understand that my attorney will attempt to negotiate the
above liens but there
is a possibility that the above liens will be the final amounts. I understand I will no
longer be able to bring any claim against the released parties and this is my final settlement for this action
I have this date read and received a copy of the above statement, which is correct and satisfactory.
I have discussed the settlement with one of my attorneys at Cantor, Wolff, Nicastro & Hall ("Law Firm")
and understand that my settlement represents a compromise between myself and the adverse party/parties
in light of issues regarding liability, damages, and the value of my claim. I had the right to pursue my
claim(s) further, including, but not limited to, taking this matter to trial, and I made the decision not to do
so. I understand that my settlement takes into account and includes all issues regarding my claim(s)
1
FILED: ERIE COUNTY CLERK 04/10/2024 12:53 PM INDEX NO. 805128/2024
NYSCEF DOC.
. NO. 9 RECEIVED NYSCEF: 04/10/2024
including such items as past and future medical bills, expenses, and lost wages unless excluded in the
Release. I understand that the settlement takes into account any and all current and potential future
injuries or treatment, including, but not limited to, future surgery, worsening of my current injuries,
injuries yet to be diagnosed. or treatment yet to be prescribed. I understand that the settlement of my
claim(s) ends the claim and my right to pursue the same in the future. I understand that by accepting the
settlement my eligibility to receive public assistance may be affected.
I have read, reviewed, and understand the Release used to settle the claim(s) and have signed
same of my own free will without any force, duress, or coercion.
Although my attorneys have not been advised of a claim against the settlement proceeds in this
matter, other than any that may be listed in this Settlement Memo, it is possible that a health insurance
carrier, HMO, Medicare, Medicaid, Social Security, Worker's Compensation, Child Support, any other
provider including hospital and doctors or any other insurance carrier or entity may assert or have a claim
or lien against the proceeds of this settlement for prior or future benefits paid to me or on my behalf or
may request an offset on future benefits paid to me. Except as disclosed on this statement, my attorneys
have not negotiated, satisfied, or withheld proceeds to satisfy any claim, lion or right which may exist and
if any do exist or become due, they will be solely my responsibility. I deny knowledge of any actual or
potential claims, liens, or rights against these settlement proceeds, other than those that may be listed
above.
I authorize and instruct Law Firm to issue checks as set forth above. I have been advised that and
agree to the above disbursements or expenses being calculated by reasonable estimates or estimated flat
fees. I believe that the case expenses and fees are fair and reasonable. I acknowledge that I have instructed
the Law Firm to dispose of all evidence pertaining to this matter and to shred my paper file including all
paper copies of my medical records and x-ray films and understand that my attorneys are not retaining
copies of same.
It is possible that claims, costs, and disbursements may have been made or incurred which change
what I am responsible to pay and can affect the net proceeds I receive.
Pursuant to Section 6(a) of the Retainer Agreement, I authorize Law Firm or his designee to
endorse settlement check(s) in my name as my Attorney-in-Fact so that the check(s) may be deposited
into the Law Firm's trust/cscrow bank account and disbursed pursuant to this Settlement Memo.
Knowing all of the above, I instruct the Law Firm to proceed to conclude this matter.
I authorize Law Firm to communicate with me and others via telephone, text, mail, delivery
service, and electronically including such means as email, networking locations, or sites regarding my
matter and my case for promotion, marketing, and advertising purposes.
I have been informed and I understand that I have the opportunity to take my case to trial. I have
been advised about the nature of litigation and the trial procedure. At trial, I would have an opportunity to
present my case and to have the judge and/or jury make a decision with respect to the issues of liability,
causation, and damages.
2
FILED: ERIE COUNTY CLERK 04/10/2024 12:53 PM INDEX NO. 805128/2024
NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 04/10/2024
I have participated in the settlement negotiation process. I understand that my case can be
tried to obtain a result, but I have directed to settle
my attorney my case. I am aware that I will have to
sign a release and my attorney will not take my case to trial. I understand that I can talk with any doctor,
lawyer, or other professional about my claims and injuries for a second opinion, before to the
agreeing
settlement.
No one has promised me anything other than the current offer. I understand that based on current
information, the gross settlement funds will be reduced by costs/disbursements; their attorney fees and
liens/subrogation/known outstanding medical bills, and as more fully detailed in the Settlement Memo
which I have reviewed and agree with. I will receive the Amount due Client outlined in the Settlement
Memo, assuming that there are no additional outstanding medical bills, disbursements, costs, liens,
claims, or rights that will further reduce the amount I receive. I am over the age of eighteen (18) and 1 can
legally conclude my case and be bound by my agreement to do so. I am also aware that by entering into
this settlernent agreernent and signing a general release, I will be bound to it forever, no matter what. I am
agreeing to this settlement voluntarily.
I understand that I may be hurt worse than I now think I am, or other injuries may
show up after I sign the release which has ended my claims. I understand that my injuries may require
additional and/or more extensive treatment including, but not limited to, surgery. I know that when I sign
the release I will be releasing all at-fault people and/or entities listed on those
documents and their insurance companies from all responsibility to me for my claims and injuries from
this incident. I understand that no matter what, the money I am being paid in exchange for the release is
all that I will ever get for any claims I made or could have made, against all responsible parties for my
injuries.
I understand that filing a lawsuit would allow for discovery which could require questions being
answered regarding insurance coverage and may result in finding additional insurance, responsible parties
and/or means of recovery.
After discussions with my attorney and weighing the risks and benefits, I have decided to end
all my claim(s) by settlement and instruct my attorney not to file a lawsuit of any kind, including
against any responsible party. I am aware that my attorney will not be pursuing any further claims on my
behalf, except to pursue any viable supplemental underinsured or uninsured motorist (SUM/UM)
coverage if any may be available. In the event there were further claims to be pursued, I am aware that
time limits and statutes of limitations could affect and limit such claims and that any recovery mentioned
in this document could limit or offset same.
Signed: Signed:
Nicholas Campas D J. Wbtff Jr .
3
Preview
FILED: ERIE COUNTY CLERK 04/10/2024 12:53 PM INDEX NO. 805128/2024 NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 04/10/2024 Settlement Statement and Consent to Settle IN RE: Nicholas Campas as PNG of G.C. (Prepared: 01/24/2024) Incident Date: 11/20/22 GROSS SETTLEMENT PROCEEDS: Gross Settlement Proceeds $50,000.00 Less Attorney's Fee (1/3rd per Retainer) $16,666.67 Total $33,333.33 Less Disbursements $400.00 Less Medicare Lien (Pending) $0.00 Less Medicaid Lien (Pending) $0.00 Less Lien $0.00 Total (Pending) $32,933.33 I DO HEREBY AUTHORIZE my attorneys, Cantor; Wolff Nicastro & Hall to endorse, deposit, and negotiate the applicable settlement draft on my behalf and; I HAVE RECEIVED AND REVIEWED a copy of the above statement, which is correct and satisfactory. I acknowledge that a physician, health care provider, health insurance carrier, HMO, PPO or any other carrier, Medicare or Medicaid, or a hospital may have a claim against the proceeds of this settlement for services or benefits paid or provided to me or on my behalf. I acknowledge that, except as disclosed on this statement, my attorneys have not negotiated, satisfied or withheld proceeds to satisfy any lien which may exist. If they have not been paid, I will be solely responsible for payment of same. I hereby authorize my attorneys to issue checks as set forth above. I understand that this will be a full and final settlement of all claims against the defendant(s) and direct Cantor, Wolff, Nicastro & Hall to accept the offer of settlement above and execute the settlement statement in the manner described above. I understand that my attorney will attempt to negotiate the above liens but there is a possibility that the above liens will be the final amounts. I understand I will no longer be able to bring any claim against the released parties and this is my final settlement for this action I have this date read and received a copy of the above statement, which is correct and satisfactory. I have discussed the settlement with one of my attorneys at Cantor, Wolff, Nicastro & Hall ("Law Firm") and understand that my settlement represents a compromise between myself and the adverse party/parties in light of issues regarding liability, damages, and the value of my claim. I had the right to pursue my claim(s) further, including, but not limited to, taking this matter to trial, and I made the decision not to do so. I understand that my settlement takes into account and includes all issues regarding my claim(s) 1 FILED: ERIE COUNTY CLERK 04/10/2024 12:53 PM INDEX NO. 805128/2024 NYSCEF DOC. . NO. 9 RECEIVED NYSCEF: 04/10/2024 including such items as past and future medical bills, expenses, and lost wages unless excluded in the Release. I understand that the settlement takes into account any and all current and potential future injuries or treatment, including, but not limited to, future surgery, worsening of my current injuries, injuries yet to be diagnosed. or treatment yet to be prescribed. I understand that the settlement of my claim(s) ends the claim and my right to pursue the same in the future. I understand that by accepting the settlement my eligibility to receive public assistance may be affected. I have read, reviewed, and understand the Release used to settle the claim(s) and have signed same of my own free will without any force, duress, or coercion. Although my attorneys have not been advised of a claim against the settlement proceeds in this matter, other than any that may be listed in this Settlement Memo, it is possible that a health insurance carrier, HMO, Medicare, Medicaid, Social Security, Worker's Compensation, Child Support, any other provider including hospital and doctors or any other insurance carrier or entity may assert or have a claim or lien against the proceeds of this settlement for prior or future benefits paid to me or on my behalf or may request an offset on future benefits paid to me. Except as disclosed on this statement, my attorneys have not negotiated, satisfied, or withheld proceeds to satisfy any claim, lion or right which may exist and if any do exist or become due, they will be solely my responsibility. I deny knowledge of any actual or potential claims, liens, or rights against these settlement proceeds, other than those that may be listed above. I authorize and instruct Law Firm to issue checks as set forth above. I have been advised that and agree to the above disbursements or expenses being calculated by reasonable estimates or estimated flat fees. I believe that the case expenses and fees are fair and reasonable. I acknowledge that I have instructed the Law Firm to dispose of all evidence pertaining to this matter and to shred my paper file including all paper copies of my medical records and x-ray films and understand that my attorneys are not retaining copies of same. It is possible that claims, costs, and disbursements may have been made or incurred which change what I am responsible to pay and can affect the net proceeds I receive. Pursuant to Section 6(a) of the Retainer Agreement, I authorize Law Firm or his designee to endorse settlement check(s) in my name as my Attorney-in-Fact so that the check(s) may be deposited into the Law Firm's trust/cscrow bank account and disbursed pursuant to this Settlement Memo. Knowing all of the above, I instruct the Law Firm to proceed to conclude this matter. I authorize Law Firm to communicate with me and others via telephone, text, mail, delivery service, and electronically including such means as email, networking locations, or sites regarding my matter and my case for promotion, marketing, and advertising purposes. I have been informed and I understand that I have the opportunity to take my case to trial. I have been advised about the nature of litigation and the trial procedure. At trial, I would have an opportunity to present my case and to have the judge and/or jury make a decision with respect to the issues of liability, causation, and damages. 2 FILED: ERIE COUNTY CLERK 04/10/2024 12:53 PM INDEX NO. 805128/2024 NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 04/10/2024 I have participated in the settlement negotiation process. I understand that my case can be tried to obtain a result, but I have directed to settle my attorney my case. I am aware that I will have to sign a release and my attorney will not take my case to trial. I understand that I can talk with any doctor, lawyer, or other professional about my claims and injuries for a second opinion, before to the agreeing settlement. No one has promised me anything other than the current offer. I understand that based on current information, the gross settlement funds will be reduced by costs/disbursements; their attorney fees and liens/subrogation/known outstanding medical bills, and as more fully detailed in the Settlement Memo which I have reviewed and agree with. I will receive the Amount due Client outlined in the Settlement Memo, assuming that there are no additional outstanding medical bills, disbursements, costs, liens, claims, or rights that will further reduce the amount I receive. I am over the age of eighteen (18) and 1 can legally conclude my case and be bound by my agreement to do so. I am also aware that by entering into this settlernent agreernent and signing a general release, I will be bound to it forever, no matter what. I am agreeing to this settlement voluntarily. I understand that I may be hurt worse than I now think I am, or other injuries may show up after I sign the release which has ended my claims. I understand that my injuries may require additional and/or more extensive treatment including, but not limited to, surgery. I know that when I sign the release I will be releasing all at-fault people and/or entities listed on those documents and their insurance companies from all responsibility to me for my claims and injuries from this incident. I understand that no matter what, the money I am being paid in exchange for the release is all that I will ever get for any claims I made or could have made, against all responsible parties for my injuries. I understand that filing a lawsuit would allow for discovery which could require questions being answered regarding insurance coverage and may result in finding additional insurance, responsible parties and/or means of recovery. After discussions with my attorney and weighing the risks and benefits, I have decided to end all my claim(s) by settlement and instruct my attorney not to file a lawsuit of any kind, including against any responsible party. I am aware that my attorney will not be pursuing any further claims on my behalf, except to pursue any viable supplemental underinsured or uninsured motorist (SUM/UM) coverage if any may be available. In the event there were further claims to be pursued, I am aware that time limits and statutes of limitations could affect and limit such claims and that any recovery mentioned in this document could limit or offset same. Signed: Signed: Nicholas Campas D J. Wbtff Jr . 3