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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/113 KB)

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