Wisconsin > Workers Comp
Compromise Agreement WKC-176 - Wisconsin
| Compromise Agreement Form. This is a Wisconsin form and can be used in Workers Comp . |
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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://dwd.wisconsin/wc e-mail: DWDDWC@dwd.wisconsin.gov Notice: To expedite processing of compromises, provide current addresses of all parties involved. 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 Name Employee Birth Date 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) 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. Employee Signature and Date Signed: Employee Attorney Signature and Date Signed: Date of Agreement: Witness Signature and Date Signed Self-Insured Employer or Insurance Carrier Signature and Date Signed: Attorney Fee: _________ Protect: ______________ Costs: WKC-176 (R. 10/2009) Percent Yes Yes No No List: American LegalNet, Inc. www.FormsWorkFlow.com
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