Third Party Proceeds Distribution Agreement

Document Number:  WKC-170

Description:  This form is to be filed by insurance carrier with the department for approval of distribution.

Comments:  This form is not fill-enabled. It can be printed and completed by hand.

Content Contact:  Kathy Froehlich

Document Attachment:  WKC-170 (pdf/11 KB)

*** If you need to access this form in an alternate format, please send an email to the Content Contact listed above.

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