Fill and Sign the Compromise Agreement Sample Form

Yes Yes No No                                                            disputed undisputed                                     Attorney Fee:       Protect:             Worker's Compensation Division Wisconsin Department of Workforce Development 201 E. Washington Ave., Rm. 161 P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 COMPROMISE AGREEMENT NOTICE: To expedite processing of compromises, provide complete current addresses of all parties involved. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)]. WC Claim Number Employee Name Employee Birth Date Employee Social Security Number Employee Mailing Address (number, street, city, state, zip code) Date of Alleged Injury Employer Name Employer Mailing Address (number, street, city, state, zip code) Insurance Company Name Insurance Company Address (number, street, city, state, zip code) It is that the employee was employed by the respondent employer. Employee Earned Weekly Wage of Compensation Previously Paid is$ $ 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: Witness Signature and Date Signed Employee Attorney Signature and Date Signed: Self-Insured Employer or Insurance Carrier Signature and Date Signed: Date of Agreement: Percent List: Costs: WKC-176 (R. 7/96)