Annual Report of Permanent Total Disability Payments Made Personal information provide d may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes]. This information is required per s. DWD 80.02 (2) (k) , Wis. Admin. Code , and is due by June 30 th of each calendar year. This is an annual follow - up for this permanent total injury. Please answer the two questions below, fill in all the appropriate payment information and return this form to the department. 1. Has there been any change in this employee's condition? Yes No 2. If applicable, indicate balance remaining on Third Party Cushion as of 12/31: $ Claimant Name WC Claim Number Employee Social Security Number Injury Date ( mm /dd/yyyy) Claimant Contact Information Insurance Company Name Note: Please report PTD/Annuity separately from Supplemental Benefits or Attorney Fees. Type of Payment Begin Date ( mm /dd/yyyy) End Date ( mm /dd/yyyy) Rate Total Amount Paid Cumulative Total Amount Paid PTD Annuity $ $ Supplemental Benefits (if applicable) $ $ Attorney Fees $ $ Total: $ Total: $ Report Prepared B y Work Telephone Number ( ) - Date Signed ( mm /dd/yyyy) WKC-17876(R. 07/2018) Department of Workforce Development P.O. Box 7901 Madison, WI 53707 Imaging Server Fax: (608) 260 - 2503 Telephone: (608) 266 - 1340 Fax: (608) 267 - 0394 http s:// dwd. wisconsin.gov/wc American LegalNet, Inc. www.FormsWorkFlow.com