ESIS Claims PO Box 6562 Scranton, PA 18505-6562 +1 913-748-8894 Tel +1 844 890-6967 Fax

ESIS Claims +1 913-748-8894 tel
PO Box 6562 +1 844 890-6967 fax

Scranton, PA 18505-6562 www.esis.com
September 4, 2020
Gordon & Partners

4114 Northlake Blvd
Palm Beach Gardens, FL 33410
ESIS File Number : 1M01M010725725

Date of Accident : 03/08/2019
ESIS Client : The Hertz Corporation
Our Renter : Misako Iwashita
Your Client : Frank Pascarella
Dear Gordon & Partners,
ESIS is the third party administrator for The Hertz Corporation.
Enclosed, please find the bodily injury release for $260,000.00, all-inclusive, for the above-referenced
loss. Upon our receipt of the properly executed Release, the settlement check will be issued.
Please contact me should you have any questions and/or concerns.
Sincerely,
Samantha Howard
Samantha Howard
Claim Representative
ESIS Claim Number: 1M01M010725725
RELEASE OF ALL CLAIMS
That the Undersigned, Frank Pascarella, being of lawful age, for the sole consideration of Two
Hundred Sixty Thousand Dollars and 00/100 ($260,000.00) to the Undersigned, in hand paid, receipt
whereof is hereby acknowledged, do/does hereby and for my/our/its heirs, executors, administrators,
successors and assigns release, acquit and forever discharge The Hertz Corporation, ESIS, Ace
American Insurance Co, Misako Iwashita, and his, her, their, or its agents, servants, successors,
heirs, executors, administrators and all other persons, firms, corporations, associations or
partnerships of and from any and all claims, actions, causes of action, demands, rights, damages,
costs, liens including Medicare liens, loss of service, expenses and compensation whatsoever, which
the undersigned now has/have or which may hereafter accrue on account of or in any way growing
out of any and all known and unknown, foreseen and unforeseen bodily and personal injuries and
property damage and the consequences thereof resulting or to result from the accident, casualty or
event which occurred on or about 03/08/2019 at or near Jupiter, FL.
It is understood and agreed that this settlement is the compromise of a disputed claim, and that the
payment made is not to be construed as an admission of liability on the part of the party or parties
hereby released, and that said Released Party denies liability therefore and intend merely to avoid
litigation and buy their peace. The Undersigned warrants that no promise or inducement has been
offered by the Released Party, except as herein set forth; that this Release is executed without
reliance upon any statement or representation by the Released Party or their representatives, or
physicians, concerning the nature and extent of the injuries and damages and legal liability therefore;
and that the Undersigned is of legal age, is legally competent to execute this Release, and accept full
responsibility for it, and that all hospital bills incurred for the treatment of the injuries for which this
settlement is made have been paid in full and all liens of said hospital have been paid and satisfied.
The Undersigned agrees as further consideration as an inducement for this compromised settlement
that the injuries sustained are permanent and progressive and recovery is uncertain and indefinite
and that the settlement and release shall apply to all unknown and unanticipated injuries and
damages resulting from said accident, casualty or event, as well as to those now disclosed.
It is the intent of the Undersigned, in signing this Release document, to release and discharge not
only the Released Party, but also any other possible joint tortfeasor who could be charged with
liability or responsibility for injuries and damages for which this Release is given. This Release
contains the entire agreement of the parties hereto, and that the terms of this Release are contractual
and not mere recital.
The Undersigned warrants as further consideration of said sum paid that no other person, firm,
corporation or government body is entitled to any claim whatsoever growing out of the aforesaid
casualty. The Undersigned will indemnify and hold harmless the Released Party from any and all
other claims which might arise from the aforesaid casualty.
Conditional Payments
It is not the purpose of this Release to shift responsibility of medical care in this matter to the
Medicare program pursuant to 42 U.S.C. Sec. 1395y(b). Instead, this settlement is intended to
resolve a dispute between the parties. The Plaintiff has been advised and fully understands that
conditional payments, if any, are the responsibility of the Undersigned, or their representatives, and
must be satisfied out of these settlement proceeds.
Page 2 of 3
PAGE INITIAL: ______
ESIS Claim Number: 1M01M010725725
Hold Harmless
The Undersigned agrees to indemnify, defend and hold the Released Party harmless from any action
by Medicare seeking payment of past, current, or future medical expenses for the Undersigned. The
Undersigned shall further hold the Released Party harmless from any and all adverse consequences
in the event this settlement results in the loss of right to Social Security and/or Medicare benefits to
the extent the Undersigned would have been entitled to those benefits in the absence of this Release.
The Undersigned and their Attorney(s) agree to hold confidential and not to disclose to any third
person or entity any information relating to the settlement reached in this claim, the claim itself, or
any incidents arising out of the claim. The Undersigned agrees that they and their attorneys will not,
directly or indirectly, discuss or otherwise disclose any of the facts underlying this claim, the
existence of this Release or the terms of the settlement to any wire service, newspaper, radio or
television reporter or any other media representative including any legal article, legal periodical,
journal, or case/settlement gathering source, or any other person or entity. The Undersigned agrees
that they and their attorneys shall respond to any inquiry regarding the resolution of the claim by
responding “The claim was dismissed by agreement of the parties. The terms of that agreement are
confidential.”
Fraud language required by jurisdiction:
THE UNDERSIGNED HAS READ THE FOREGOING RELEASE AND FULLY

UNDERSTANDS IT.
Signed, sealed and delivered this _____________ day of________ 20_____
CAUTION: READ BEFORE SIGNING BELOW
_________________________________ Frank Pascarella

__________________________________
Claimant Signature Claimant Printed Name
_________________________________ __________________________________
Witness Signature Witness Printed Name
NOTARY:
State of __________________________; County of _________________________
On this ____________ day of _______________, 20_______, before me appeared
___________________________________________________________________
Who is known to be the person(s) named herein and who voluntarily executed this release.
____________________________________________________
Notary Signature
Date Commission Expires:
Page 3 of 3
PAGE INITIAL: ______

ESIS Claims PO Box 6562 Scranton, PA 18505-6562 +1 913-748-8894 Tel +1 844 890-6967 Fax

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ESIS Claims PO Box 6562 Scranton, PA 18505-6562 +1 913-748-8894 Tel +1 844 890-6967 Fax

Uploaded by

Copyright:

Available Formats

ESIS Claims +1 913-748-8894 tel

PO Box 6562 +1 844 890-6967 fax

Gordon & Partners

ESIS File Number : 1M01M010725725

Dear Gordon & Partners,

ESIS is the third party administrator for The Hertz Corporation.

Please contact me should you have any questions and/or concerns.

Fraud language required by jurisdiction:

THE UNDERSIGNED HAS READ THE FOREGOING RELEASE AND FULLY

Signed, sealed and delivered this _________ day of 20_

CAUTION: READ BEFORE SIGNING BELOW

_________________________________ Frank Pascarella

State of __; County of _

On this ____ day of _, 20_, before me appeared

Date Commission Expires:

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