Fill and Sign the Wkc 176 Compromise Agreement This Form is to Be Filed When There is Approval of Compensation Receiving a Dispute

COMPROMI SE AGREEMENT Notice: To expedite processing of compromises, provide current addresses of all parties involved. *Provision of your Social Security Number (SSN) is voluntary . Failure to provide it may result in an information processing delay. Personal i nformation you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes]. WC Claim Number Employee Name Employee Birth Date Employee Social Security Number * Employee Mailing Address (number, street, city, state, zip cod e) Date of Alleged Injury Employer Name Employer Address (number, street, city, state, zip code) Insurance Company Name Insurance Company Address (number, street, city, state, zip code) It is disputed undisputed t hat 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 ag reement 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 f act 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: Attorney Fee: _________ Percent List: Protect: ______________ Yes No Costs: Yes No WKC -176 (R. 06/20 17) 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 .gov /wc e-mail: DWDDWC@dwd.wisconsin.gov