Get Wisconsin Third Party Proceeds Distribution Agreement

This guide provides a step-by-step approach to filling out the Wisconsin Third Party Proceeds Distribution Agreement online. Whether you are familiar with legal documents or not, these instructions will help you navigate the form with ease.

Follow the steps to complete the agreement accurately and efficiently.

1. Click ‘Get Form’ button to access the Wisconsin Third Party Proceeds Distribution Agreement and open it in your chosen document editor.
2. Enter the WC claim number in the designated field to identify the claim associated with the third party proceeds.
3. Provide the employee's full name as it appears on relevant documents.
4. Optionally, enter the Social Security Number (SSN). Note that failing to provide the SSN may lead to processing delays.
5. Fill in the employee's mailing address, including the number, street, city, state, and zip code.
6. Specify the date of the injury in the relevant section.
7. Indicate the employer's name associated with the worker's compensation claim.
8. Input the insurance claim number related to the injury.
9. Enter the employer's mailing address in the required format.
10. List the name of the worker’s compensation insurance carrier or self-insured employer.
11. Identify the person submitting the agreement and provide their mailing address.
12. In the section regarding liabilities, document the total amount of the third-party settlement.
13. Detail the amount allocated to the employee's attorney for costs, including fees.
14. Input one-third of the balance to be distributed to the employee.
15. Document the reimbursement amount to the worker’s compensation insurance carrier or self-insured employer for compensation paid.
16. Specify the medical expense amount to be reimbursed.
17. List the remaining balance allocated to the employee as a cushion or credit against any future claims under worker’s compensation.
18. Ensure all signatures are present. This includes the employee, attorney, and the worker’s compensation insurance carrier or self-insured employer.
19. Finally, save your changes, download, print, or share the completed agreement as needed.

Begin completing your Wisconsin Third Party Proceeds Distribution Agreement online today.