Personal Injury Settlement Statement Template
(Free Download)
Free personal injury settlement statement template for plaintiff-side contingency law firms
A complete, print-ready PI settlement statement template — covering attorney fees, case costs, medical liens, Medicare/Medicaid, ERISA subrogation, and client net recovery. Download the PDF, fill in the numbers, and collect signatures.
- All required line items: gross settlement, fees, costs, liens, net recovery
- Medical lien table with claim, agreed, and paid amount columns
- Medicare, Medicaid, and ERISA subrogation sections
- Signature lines for attorney and client
What goes on a settlement statement
A personal injury settlement statement is the financial record that shows every dollar of the gross settlement and where it goes. Every PI attorney should know each line item — and so should the client before signing. Here is what belongs on a complete settlement statement.
Gross settlement amount
The total dollar amount agreed to by the defendant or their insurer. This is the starting figure from which all deductions are made. It should match the settlement agreement exactly.
Attorney fees (with % shown)
The contingency fee amount, calculated by multiplying the gross settlement by the agreed percentage. Best practice is to show both the percentage and the resulting dollar amount so the client can verify the arithmetic.
Case costs (itemized)
Advanced expenses the firm paid on the client's behalf — filing fees, expert witness fees, medical records costs, deposition transcripts, investigation costs. Each line item should be described individually. Lumping costs into a single number is inadequate documentation.
Medical liens
Amounts owed to treating medical providers who accepted assignment of benefits from the settlement. Show the provider name, original billed amount, negotiated/agreed amount, and the amount being paid. The delta between billed and paid demonstrates the attorney's lien negotiation work on behalf of the client.
Medicare / Medicaid liens
Federal and state government healthcare programs that paid for injury-related treatment have statutory reimbursement rights that must be satisfied before the client receives their share. Use the final demand figure from the government agency, not the conditional payment estimate.
ERISA subrogation
Employer-sponsored health plans governed by ERISA may have a right to recover benefits paid for the injury from the settlement proceeds. This is a separate line from medical provider liens. The plan's summary plan description governs the reimbursement right.
Referral fees out
If a referring attorney is entitled to a portion of the contingency fee under a written fee-sharing agreement and client disclosure, the referral fee should be shown as a separate line item, not buried in the attorney fee line. This is required for transparency and bar compliance in most states.
Client net recovery
The amount the client receives after all deductions. This is the bottom line the client is most focused on and the figure that drives any fee dispute. It must equal: gross settlement minus attorney fees minus referral fees minus case costs minus all lien payments.
Download the free PDF template.
A print-ready personal injury settlement statement template with all required sections — attorney fees, case costs, medical liens, Medicare/Medicaid, ERISA subrogation, referral fees, and client net recovery — with signature lines for attorney and client. Enter your email and we'll send it over.
How to fill out each section
Walk through the template section by section. The numbers below use a $150,000 hypothetical settlement to illustrate how each calculation works.
Enter the gross settlement amount
Start with the total agreed settlement figure from the settlement agreement or release. Confirm this matches the amount that will be deposited into your IOLTA trust account. Do not net anything at this stage — list the full gross amount.
Calculate and enter attorney fees
Multiply the gross settlement by the contingency percentage from the fee agreement. Example: $150,000 × 33.33% = $49,995. Enter both the percentage and the dollar amount. If there is a co-counsel or referral fee split, enter it as a separate line under referral fees out, not as a reduction to your fee.
List and total case costs
Pull your matter ledger and list each advanced expense by category: filing fees, expert fees, medical records, court reporter fees, investigation costs, etc. Enter a description and dollar amount for each. Sum them for the total case costs line. Retain receipts for each item.
Enter each medical lien
For each medical provider that has a lien, enter: (a) the provider name, (b) the original billed or claimed amount, (c) the agreed or negotiated reduced amount, and (d) the amount you will pay at settlement. Example: Hospital A billed $28,000, negotiated down to $14,000, paying $14,000. The 'paid amount' column drives the actual payment.
Enter Medicare / Medicaid amounts
Enter the final demand figure from Medicare's BCRC or your state's Medicaid agency. If you have not yet received a final demand, do not close the settlement — estimate at the conditional payment amount and hold funds in trust until the final demand arrives. Note the demand date on the statement.
Enter ERISA subrogation
Contact the employer's health plan administrator to determine if there is an ERISA subrogation claim. If so, enter the claim amount and any negotiated reduction. If no ERISA plan was involved, leave this section blank or enter $0.
Calculate client net recovery
Subtract all deductions from the gross settlement: Gross − Attorney Fees − Referral Fees Out − Case Costs − Medical Lien Payments − Medicare/Medicaid − ERISA Subrogation = Client Net. Verify the math sums to zero: all deductions plus client net should equal gross settlement exactly.
Review with client and collect signatures
Walk the client through each line item before asking for a signature. The client should understand what each deduction is and why it is being paid. Once the client signs, file the signed statement in the matter record and disburse funds from the IOLTA account.
Common mistakes on PI settlement statements
These errors appear regularly in bar complaints, fee disputes, and audit findings. Knowing them in advance makes them avoidable.
Using a conditional Medicare payment estimate instead of the final demand
The conditional payment notice is an estimate. Only the final demand letter from Medicare's BCRC gives you the actual reimbursement amount. Disbursing before you have the final demand — and using the estimate — can leave you personally liable for the difference if Medicare's actual claim is higher.
Failing to itemize case costs
Listing 'case expenses: $4,200' as a single line provides no documentation if the client disputes the deduction. Every advanced expense should be its own line item with a description. This also protects the firm during bar audits.
Burying referral fees in the attorney fee line
Most state bar rules require the client to have consented to fee sharing in writing and require the allocation between firms to be disclosed. Combining your fee and the referral fee into one number hides the division and can create bar compliance problems.
Paying lien amounts before the lien is confirmed in writing
Do not use verbal representations from providers to fill in the 'agreed amount' column. Get written confirmation — a lien reduction letter or settlement agreement with the provider — before entering the negotiated amount and before disbursing.
Disbursing before the client signs the statement
The client's signature authorizes the disbursement. Releasing funds before obtaining that signature — even if the client verbally agreed — leaves the firm without documented authorization and exposes it to a fee dispute or bar complaint.
Omitting ERISA subrogation entirely
If the client had employer-sponsored health insurance that paid for injury treatment, there may be an ERISA subrogation obligation regardless of state anti-subrogation law. Failing to investigate ERISA claims and leaving them off the settlement statement can result in the plan suing both the client and the firm after settlement closes.
When a template isn't enough
A PDF template solves the document problem, not the disbursement problem. You still have to calculate every line manually, check every lien amount against a separate spreadsheet, validate that the total doesn't exceed the IOLTA trust balance, and then write — or wire — eight separate payments one by one.
Disbo automates what comes after the template. It reads your settlement statement, pulls confirmed lien amounts from your lien negotiation records, validates the math against your IOLTA trust balance, and pays every party simultaneously — attorney fees, medical providers, lien holders, and the client — from one authorization.
The complete PI settlement disbursement workflow and all product capabilities are described on the features page.
See Disbo in actionTemplate vs. Disbo
Settlement statement common questions.
A personal injury settlement statement is a financial document prepared by the plaintiff's attorney that shows how gross settlement proceeds are divided among all parties. It lists the gross settlement amount, attorney fees, case costs, medical lien payments, government lien reimbursements (Medicare, Medicaid), any ERISA subrogation obligations, and the net amount the client receives. The client signs the statement to authorize the disbursement before any funds are released from the IOLTA trust account.
The two terms are often used interchangeably in plaintiff-side PI practice. A settlement statement (sometimes called a settlement sheet, closing statement, or disbursement worksheet) is the document that shows the math — how every dollar of the gross settlement is allocated. A disbursement sheet may refer to the same document or to an internal record tracking the actual payments made. The template on this page serves both purposes.
At minimum, a PI settlement statement should include: the gross settlement amount; attorney fees with the contingency percentage shown; itemized case costs; medical lien amounts broken down by provider (showing the original claim amount, agreed reduction, and amount paid); Medicare and Medicaid conditional payment amounts; any ERISA or private health insurance subrogation; referral fees paid to co-counsel; and the client net recovery. Signature lines for both attorney and client complete the document.
Yes. In virtually every state, bar rules require the client to approve and sign the settlement disbursement statement before the attorney disburses funds from the trust account. The signed statement documents the client's informed consent to the allocation of proceeds, protects the attorney in the event of a fee dispute, and is required evidence if a bar audit reviews the matter file.
Medical liens should be listed by provider with three amounts shown for each: the original billed or claimed amount, the agreed or negotiated reduction amount, and the actual amount being paid at settlement. Showing all three figures demonstrates that the attorney negotiated the lien and documents the savings to the client. The template on this page includes a four-column medical lien table for exactly this purpose.
When Medicare has paid for treatment related to the injury, it has a conditional payment lien that must be repaid from the settlement. The attorney should obtain a final demand letter from Medicare's Benefits Coordination & Recovery Center (BCRC) before disbursement. The final demand amount — not the conditional payment notice amount — goes on the settlement statement as the Medicare reimbursement line. Failing to reimburse Medicare is a federal violation that can result in double damages.
ERISA subrogation arises when a client's employer-sponsored health insurance plan (governed by ERISA) paid for medical treatment related to the injury. ERISA plans have a federal right to recover those payments from a personal injury settlement. The plan's subrogation claim — after any negotiated reduction — should appear as a separate line item on the settlement statement. Unlike state-law liens, ERISA subrogation rights are governed by federal law and may not be reduced by the make-whole doctrine in all circuits.
A template is a starting point — it gives you the structure, but you still have to fill in every number manually, recalculate totals, and process each payment separately. Disbo automates the entire settlement disbursement workflow: it reads the settlement statement, pre-populates payee amounts from your lien negotiation records, validates the math against the IOLTA trust balance, and pays all parties simultaneously from the trust account. The template on this page is a free resource for firms that aren't yet using Disbo. See the full disbursement workflow at the link below.