Fill and Sign the Wkc 177 Stipulation This Form is to Be Filed by the Parties as to Facts of the Case

STIPUL ATION *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 Employee Birth Date Employee Social Security Number * Employee Mailing Address (Number, Street) Employee Mailing Address (City, State, Zip Code) Date of Alleged Injury Employer Name Employer Mailing Address (Number, S treet) Employer Mailing Address (City, State, Zip Code) Insurance Company Name Insurance Company Address (Number, Street) Insurance Company Address (City, State, Zip Code) Employee’s Average W eekly W age at Time of Injury: $____________________ ______ Temporary Disability: From To From To From To Permanent Disability Conceded %: __________ W eeks ___________ $ ___________________ Compensation Paid $ _________________ Attorney Fee $ ________________________ Medical Expenses to be Paid: _____________________________________________________ $ _______________________________ _____________________________________________________ $ _______________________________ _____________________________________________________ $ _______________________________ _____________________________________________________ $ _______________________________ _____________________________________________________ $ _______________________________ Employee Signature Date Signed Insurance Co. Representative or Self -Insured Employer Signature Date Signed Note: Attach all medical reports. WKC -177 (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://www.dwd.wisconsin .gov /wc e-mail: DWDDWC@dwd.wisconsin.gov