Free WKC-176.PDF - Wisconsin

COMPROMISE 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]

Notice: To expedite processing of compromises, provide current addresses of all parties involved.
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)]. WC Claim Number Employee Name Employee Social Security Number Date of Alleged Injury Insurance Company Name Employee Mailing Address (number, street, city, state, zip code) Employer Name Employer Address (number, street, city, state, zip code) Employee Birth Date

Insurance Company Address (number, street, city, state, zip code)

It is

disputed

undisputed that the employee was employed by the respondent employer
Compensation Previously Paid Is

Employee Earned Weekly Wage of

$ The conceded disability is:

$

There is a bona fide dispute between the parties as to whether the employee:

Therefore the parties, subject to the approval of the Department of Workforce Development, agree to a Compromise Settlement as follows:

NOTICE TO EMPLOYEE:

The employee has the right to petition the Department of Workforce Development to set aside or modify this compromise agreement within one year of its approval by the department. The department may set aside or modify the compromise agreement. The right to request the department to set aside or modify the compromise agreement does not guarantee that the compromise will in fact be reopened.
Witness Signature and Date Signed Self-Insured Employer or Insurance Carrier Signature and Date Signed:

Employee Signature and Date Signed: Employee Attorney Signature and Date Signed: Date of Agreement:

Attorney Fee: _________ Protect: ______________ Costs:
WKC-176 (R. 07/2001)

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