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  2. Forms Repository
  3. WKC-170-E, Third Party Proceeds Distribution Agreement

Third Party Proceeds Distribution Agreement

Document Number: WKC-170-E

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

Comments: This form is an electronic Microsoft Word template that can be filled out on your computer (if you have Microsoft Word). An electronic PDF (WKC-170-E) is also provided for your convenience.

Content Contact: Lynn Weinberger

Document Attachments:

WKC-170-E (Electronic Version - Word/54 KB)

WKC-170-E (Electronic Version - pdf/160 KB)

Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.

Contact Information

For questions about this form, or if you need this form in an alternate format, please see the Content Contact (listed to the left)

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