Free WKC-177.PDF - Wisconsin

STIPULATION

Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)]. WC Claim Number Employee Social Security Number Employee Name Employee Mailing Address (Number, Street)

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] Employee Birth Date

Employee Mailing Address (City, State, Zip Code) Date of Alleged Injury Employer Name Employer Mailing Address (Number, Street)

Employer Mailing Address (City, State, Zip Code) Insurance Company Name Insurance Company Address (Number, Street)

Insurance Company Address (City, State, Zip Code)

Employee's Average Weekly Wage at Time of Injury: $__________________________ Temporary Disability: From From From

To To To

Permanent Disability Conceded %: __________

Weeks ___________

$ ___________________

Compensation Paid $ _________________ Attorney Fee $ ________________________ Medical Expenses to be Paid:

_____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________
Employee Signature Insurance Co. Representative or Self-Insured Employer Signature

$ _______________________________ $ _______________________________ $ _______________________________ $ _______________________________ $ _______________________________

Date Signed Date Signed

Note: Attach all medical reports.

WKC-177 (R. 07/2001)