Fill and Sign the Wkc 170 Third Party Proceeds Distribution Agreement This Form is to Be Filed by Insurance Carrier with the Department for

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) Worker’s Compensation Insurance Carrier 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. $ to employee’s attorney as cost of collection (fee & costs) 3. $ one -third of balance to employee 4. $ to worker’s compensation insurance carrier or self -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 against any additional claim under worker’s compensation PLEASE 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, W orker’s Compensation Division WKC -170 (R. 06/201 7) Department of Workforce Development Worker’s Compensation Division 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