Third Party Proceeds Distribution Agreement {WKC-170}

THIRD PAR TY PROCEEDS DISTRIBUTION AGREEMENT * 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 Social Security Number * Employee Mailing Address (number, street, city, state, zip code) Injury Date Employer Name Insurance Claim Number Employer Mailing Address (number, street, city, state, zip code) Submitted By 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 sustain ed on The proceeds will be distributed according to the provisions of 102.29, Wisconsin Statutes, as follows: 1. $ total amount of third party settlement 2. $ collection (fee & costs) 3. $ one - third of balance to employee 4. $ - insured employer as reimbursement for payment of $ in compensation, an d $ in medical expense 5. $ balance to employee which shall constitute a cushion or credit PLEASE NOTE: APPROVAL VOID IF PROCEEDS RESULT FROM UNINSURED MOTORIST PROVISION Employee Signature Attorney Signature Agreement Date - Insured Employer Signature SETTLEMENT AND DISTRIBUTION OF PROCEEDS AS STATED ABOVE ARE APPROVED. Date Signed WKC - 170 ( R . 06 /201 7 ) Department of Workforce Development 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707 Telephone: (608) 266 - 1340 Fax: (608) 267 - 0394 http://www.dwd.wisconsin .gov /wc e - mail: DWDDWC@dwd.wisconsin.gov American LegalNet, Inc. www.FormsWorkFlow.com