COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : THIRD PARTY PROCEEDS DISTRIBUTION AGREEMENT Plaintiff(s) : : Department of Workforce Development Worker’s Compensation Division 201 E. Index No. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Calendar No. (608) 266-1340 Telephone: Fax: (608) 267-0394 http://www.dwd.state.wi.us/wc/ JUDICIAL SUBPOENA e-mail: DWDDWC@dwd.state.wi.us Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m)]. -against: WC Claim Number Employee Name Social Security Number Employee Mailing Address (number, street, city, state, zip code) Injury Date Employer Name : : Defendant(s) : ...................................................... Insurance Claim Number Employer Mailing Address (number, street, city, state, zip code) Worker’s Compensation Insurance Carrier THE PEOPLE OF THE STATE OF NEW YORK Submitted By Mailing Address (number, street, city, state, zip code) TO ________________________________________________________________________, insurer of GREETINGS: _______________________________________________________, third party, and the above parties have WE COMMAND YOU, that all business and excuses being laid aside, you and each of you agreed to settle the liability of the tort-feasor for injury sustained on ____________________________. attend before , the Honorable at the Court located at County of distributed according to the provisions of 102.29, Wisconsin Statutes, as follows: The proceeds will be in room , on the day of , 20 , at o'clock in the noon, and at any recessed 1. $_______________________________ evidence as a witness in party settlement part of the or adjourned date, to testify and give total amount of third this action on the 2. $_______________________________ to employee’s attorney as cost of collection (fee & costs) 3. $_______________________________ this subpoena balance to employee Your failure to comply with one-third of is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a 4. $_______________________________ to worker’s compensation insurance carrier or self-insured result of your failure to comply. employer as reimbursement for payment of Witness, Honorable $______________ in compensation, and Court in County, day of $______________ in medical expense , one of the Justices of the , 20 5. $_______________________________ balance to employee which shall constituteandcushion or credit a type name below) (Attorney must sign above against any additional claim under worker’s compensation PLEASE NOTE: APPROVAL VOID IF PROCEEDS RESULT FROM Employee Signature UNINSURED MOTORIST PROVISION Attorney Signature Agreement Date Worker’s Compensation Insurance Carrier or Self-Insured Employer Signature Attorney(s) for Office and P.O. Address SETTLEMENT AND DISTRIBUTION OF PROCEEDS AS STATED ABOVE ARE APPROVED. ______________________________________ Date Signed WKC-170 (R. 07/2001) Telephone No.: Facsimile No.: _______________________________________________________ E-Mail Address: Administrative Law Judge, Worker’s Compensation Division Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com