Free WKC-170.PDF - Wisconsin

THIRD PARTY PROCEEDS DISTRIBUTION AGREEMENT

Department of Workforce Development Worker's Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://www.dwd.state.wi.us/wc/ e-mail: [email protected]

Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m)]. WC Claim Number Social Security Number Injury Date Insurance Claim Number Worker's Compensation Insurance Carrier Submitted By Mailing Address (number, street, city, state, zip code) Employee Name Employee Mailing Address (number, street, city, state, zip code) Employer Name Employer Mailing Address (number, street, city, state, zip code)

________________________________________________________________________, insurer of _______________________________________________________, third party, and the above parties have agreed to settle the liability of the tort-feasor for injury sustained on ____________________________. The proceeds will be distributed according to the provisions of 102.29, Wisconsin Statutes, as follows: 1. $_______________________________ 2. $_______________________________ 3. $_______________________________ 4. $_______________________________ $______________ in compensation, and $______________ in medical expense 5. $_______________________________ balance to employee which shall constitute a cushion or credit against any additional claim under worker's compensation
PLEASE NOTE: APPROVAL VOID IF PROCEEDS RESULT FROM UNINSURED MOTORIST PROVISION
Agreement Date Employee Signature Attorney Signature

total amount of third party settlement to employee's attorney as cost of collection (fee & costs) one-third of balance to employee to worker's compensation insurance carrier or self-insured employer as reimbursement for payment of

Worker's Compensation Insurance Carrier or Self-Insured Employer Signature

SETTLEMENT AND DISTRIBUTION OF PROCEEDS AS STATED ABOVE ARE APPROVED.

______________________________________ Date Signed
WKC-170 (R. 07/2001)

_______________________________________________________ Administrative Law Judge, Worker's Compensation Division