STIPULATION
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)]. WC Claim Number Employee Social Security Number Employee Name Employee Mailing Address (Number, Street)
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.state.wi.us/wc/ e-mail: [email protected] Employee Birth Date
Employee Mailing Address (City, State, Zip Code) Date of Alleged Injury Employer Name Employer Mailing Address (Number, Street)
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 Weekly Wage at Time of Injury: $__________________________ Temporary Disability: From From From
To To To
Permanent Disability Conceded %: __________
Weeks ___________
$ ___________________
Compensation Paid $ _________________ Attorney Fee $ ________________________ Medical Expenses to be Paid:
_____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________
Employee Signature Insurance Co. Representative or Self-Insured Employer Signature
$ _______________________________ $ _______________________________ $ _______________________________ $ _______________________________ $ _______________________________
Date Signed Date Signed
Note: Attach all medical reports.
WKC-177 (R. 07/2001)