Wisconsin > Workers Comp
Stipulation (As To Facts Of Case) WKC-177 - Wisconsin
| Stipulation (As To Facts Of Case) Form. This is a Wisconsin form and can be used in Workers Comp . |
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STIPULATION Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes]. 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.wisconsin.gov/wc e-mail: DWDDWC@dwd.wisconsin.gov 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. 10/2009) American LegalNet, Inc. www.FormsWorkFlow.com
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