Wisconsin > Workers Comp
Third Party Proceeds Distribution Agreement WKC-170 - Wisconsin
| Third Party Proceeds Distribution Agreement Form. This is a Wisconsin form and can be used in Workers Comp . |
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THIRD PARTY PROCEEDS DISTRIBUTION 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 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 Social Security Number Injury Date Insurance Claim Number Worker's Compensation Insurance Carrier Submitted By Mailing Address (number, street, city, state, zip code) Employee Name Employee Mailing Address (number, street, city, state, zip code) Employer Name Employer Mailing Address (number, street, city, state, zip code) ________________________________________________________________________, insurer of _______________________________________________________, third party, and the above parties have agreed to settle the liability of the tort-feasor for injury sustained on ____________________________. The proceeds will be distributed according to the provisions of 102.29, Wisconsin Statutes, as follows: 1. $_______________________________ 2. $_______________________________ 3. $_______________________________ 4. $_______________________________ $______________ in compensation, and $______________ in medical expense 5. $_______________________________ balance to employee which shall constitute a cushion or credit against any additional claim under worker's compensation PLEASE NOTE: APPROVAL VOID IF PROCEEDS RESULT FROM UNINSURED MOTORIST PROVISION Agreement Date Employee Signature total amount of third party settlement to employee's attorney as cost of collection (fee & costs) one-third of balance to employee to worker's compensation insurance carrier or self-insured employer as reimbursement for payment of Attorney Signature Worker's Compensation Insurance Carrier or Self-Insured Employer Signature SETTLEMENT AND DISTRIBUTION OF PROCEEDS AS STATED ABOVE ARE APPROVED. ______________________________________ Date Signed WKC-170 (R. 10/2009) _______________________________________________________ Administrative Law Judge, Worker's Compensation Division American LegalNet, Inc. www.FormsWorkFlow.com
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