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Agreement To Execute--Accidental Injuries
AGREEMENT TO EXECUTE-ACCIDENTAL INJURIES
Agreement made on [Date of Agreeement], between [Name of Covenantor], of [Address of Covenantor], and [Name of Covenantee], of [Address of Covenantee].
In consideration of the payment to me by [Name of covenantee] of the sum of $ [Amount paid] Dollars, receipt whereof is hereby acknowledged, I hereby undertake and agree that on the payment to me at any time on or before [Date of next payment] of the further sum of $ [Amount of next payment], I will execute and deliver to [Name of covenantee] a covenant not to sue [him or her] on any claim or cause of action that I may have against [him or her], arising out of a certain accident that occurred at [Place of Accident], on or about [Date of Accident].
The covenant not to sue shall be in the form attached and made a part of this document.
The payment to me shall be made either to myself at [Address to make payment], or to my attorney, [Name of Attorney], of [Address of Attorney], and may be made in the form of cash, cashier's check or draft, the payment of which is guaranteed by [Name of Guarantor], of [Address of Guarantor].
If I refuse to execute a covenant not to sue, then on payment of the sum of $ [Amount of next payment] to either myself or the above-mentioned [Name of Attorney], this agreement will be deemed to operate as such covenant not to sue and the terms of the covenant not to sue attached to this document shall be binding on me as if then executed.
In witness whereof, the parties have executed this agreement at [Place of execution] the day and year first above written.
Signature Date
Signature Date
( Attach statement of attorney, if desired.)