Fill and Sign the Wi Workers Compensation 497431470 Form

                                                                             agreed to settle the liability of the tort-feasor for injury sustained on       1.$       2.$       3.$       4.$       $       $       5.$                   THIRD PARTY PROCEEDS DISTRIBUTION AGREEMENT Department of Workforce Development Worker's Compensation Division 201 E. Washington Avenue, Rm. 161P.O. Box 7901Madison, WI 53707-7901Telephone: (608) 266-1340 Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)]. 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) Worker's Compensation Insurance Carrier Submitted By Mailing Address (number, street, city, state, zip code) , insurer of , third party, and the above parties have The proceeds will be distributed according to the provisions of 102.29, Wisconsin Statutes, as follows: 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 in compensation, and in medical expense balance to employee which shall constitute a cushion or credit against any additional claim under worker's compensationPLEASE NOTE: APPROVAL VOID IF PROCEEDS RESULT FROM UNINSURED MOTORIST PROVISION Employee Signature Attorney Signature Agreement Date Worker's Compensation Insurance Carrier or Self-Insured Employer Signature SETTLEMENT AND DISTRIBUTION OF PROCEEDS AS STATED ABOVE ARE APPROVED. Date Signed Administrative Law Judge, Worker's Compensation Division WKC-170 (R. 11/96)