COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : COMPROMISE AGREEMENT : : Plaintiff(s) -against- Department of Workforce Development Worker’s Compensation Division 201 E. Washington Ave., Rm. C100 IndexBox 7901 No. P.O. Madison, WI 53707-7901 Telephone: (608) Calendar No. 266-1340 Fax: (608) 267-0394 http://www.dwd.state.wi.us/wc/ e-mail: DWDDWC@dwd.state.wi.us JUDICIAL SUBPOENA : Notice: To expedite processing of compromises, provide current addresses of all parties involved. : Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)]. WC Claim Number Employee Name Employee Birth Date : Employee Social Security Number Employee Mailing Address (number, street, city, state, zip code) Date of Alleged Injury Employer Name Insurance Company Name Insurance Company Address (number, street, city, state, zip code) Defendant(s) : ...................................................... Employer Address (number, street, city, state, zip code) THE PEOPLE OF THE STATE OF NEW YORK It is disputed TO undisputed that the employee was employed by the respondent employer Employee Earned Weekly Wage of Compensation Previously Paid Is $ $ The conceded disability is: GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of There is a bona fide dispute between the parties as to whether the employee: in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to approval of the Department of Workforce Development, agree to a will make you Therefore the parties, subject to the comply with this subpoena is punishable as a contempt of court andCompromise liable to Settlement as follows: whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a the party on result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) NOTICE TO EMPLOYEE: The employee has the right to petition the Department of Workforce Development to set aside or modify this compromise agreement within one year of its approval by the department. The department may set aside or modify the compromise agreement. The right to request the Attorney(s) for department to set aside or modify the compromise agreement does not guarantee that the compromise will in fact 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: Office and P.O. Address Date of Agreement: Attorney Fee: _________ Protect: ______________ Costs: WKC-176 (R. 07/2001) Percent List: Telephone No.: Yes Facsimile No.: No Yes E-Mail Address: No Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com