Stipulation (As To Facts Of Case) {WKC-177}

WKC-177 - STIPULATION. This form is used by the Wisconsin Department of Workforce Development’s Worker’s Compensation Division to record an agreement between an injured employee, their employer, and the employer’s insurance company regarding the payment of worker’s compensation benefits. This form documents important details such as the employee’s personal information, the employer’s and insurer’s information, the date of the alleged injury, the employee’s average weekly wage, and the benefits being agreed upon. It includes sections for temporary and permanent disability benefits, compensation amounts, attorney fees, and medical expenses to be paid. By signing this stipulation, all parties acknowledge and agree to the outlined terms of compensation under Chapter 102 of the Wisconsin Statutes. Medical reports must be attached to support the agreement, and while providing a Social Security Number is voluntary, failure to do so may delay processing. www.FormsWorkflow.com