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). If you do not have Microsoft Word we are providing a PDF (WKC-170) which you can print and complete by hand.

Content Contact: Lynn Weinberger

Document Attachments:

WKC-170-E (Electronic Version - Word/49 KB)

WKC-170 (Print Version - pdf/131 KB)

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