Third Party Proceeds Distribution Agreement {WKC-170}

WKC-170-E - THIRD PARTY PROCEEDS DISTRIBUTION AGREEMENT. This form is to be filed by insurance carrier with the department for approval of distribution. The form is used to document and authorize the distribution of settlement proceeds obtained from a third-party tortfeasor in cases involving a worker’s compensation injury. Under Wisconsin law, when an injured employee receives a settlement from a third party responsible for the injury, portions of the proceeds must be allocated to reimburse the worker’s compensation insurance carrier or self-insured employer for compensation and medical expenses already paid, cover attorney fees and costs, and provide the employee with any remaining balance. This form records the total settlement amount, the allocation to the employee’s attorney, the portion payable to the employee, the reimbursement to the insurer or self-insured employer, and any remaining funds set aside as a cushion or credit against future claims. The form requires signatures from the employee, the employee’s attorney, and the insurance carrier or self-insured employer, and it must be approved by an Administrative Law Judge in the Worker’s Compensation Division to be valid. www.FormsWorkflow.com