COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : EMPLOYERS' SUPPLEMENTAL REPORT Index No. STATE OF MAINE WORKERS' COMPENSATION BOARD : Calendar No. STATION 27, AUGUSTA, MAINE 04333-0027 : Plaintiff(s) 1. INSURER FILE NUMBER: JUDICIAL SUBPOENA 7. WCB FILE NUMBER: 6. SOCIAL SECURITY NUMBER -against2. EMPLOYER NAME: : 8. EMPLOYEE LAST NAME: 9. FIRST NAME: 10. M.I.: : 3. EMPLOYER MAILING ADDRESS AND PHONE NUMBER: 11. ADDRESS-NUMBER AND STREET: : Defendant(s) 12. CITY: : 13. STATE: ...................................................... 4. INSURER NAME: 5. INSURER MAILING ADDRESS: 16. DATE OF INJURY: 14. ZIP: 15. HOME PHONE: 17. DESCRIPTION OF INJURY: THE PEOPLE OF THE STATE OF NEW YORK NOTICE TO EMPLOYER TO THIS REPORT IS USED ONLY WHEN THE EMPLOYEE LOSES A DAY OR MORE FROM WORK THAT DOES NOT RESULT IN THE FILING OF A MEMORANDUM OF PAYMENT, A NOTICE OF CONTROVERSY OR IF BOXES 39 AND 40 OF THE FIRST REPORT, WCB-1, ARE COMPLETED OR CORRECTED AS APPLICABLE. THE EMPLOYER SHALL FILE THIS REPORT TO THE BOARD ADDRESS LISTED ABOVE WITHIN SEVEN DAYS OF THE EMPLOYEE'S RETURN TO WORK (SEE RULE 8.16) GREETINGS: 18. ON WHAT DATE DID THIS EMPLOYEE BEGIN LOSING TIME FROM WORK? MONTH DAY YEAR HOUR AM / / : WE COMMAND YOU, that all business and excuses being laid aside, you and each ofPM attend before you , the Honorable at the Court 19. ON WHAT DATE DID THE EMPLOYEE RETURN TO WORK? MONTH DAY YEAR HOUR AM located at County of / / : PM in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 20. IS THE INJURED EMPLOYEE EARNING THE SAME WEEKLY WAGES AS BEFORE THE INJURY? YES NO 21. DID THIS EMPLOYEE RETURN TO WORK WITH A DIFFERENT EMPLOYER? IF YES, GIVE NAME(S) Your failure to comply with this subpoena is punishable as a contempt YES of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a NO result of your failure to comply. 22. COMMENTS: Witness, Honorable Court in County, , one of the Justices of the day of 20 ASSISTANCE IS AVALABLE AT THE, BOARD'S REGIONAL OFFICES: AUGUSTA 24 STONE ST AUGUSTA, ME 04330-5220 287-2168 1-800-400-6854 BANGOR CARIBOU 106 HOGAN RD. ONE VAUGHN PLACE BANGOR, ME 04401-5640 (Attorney must sign above DR,type name below) 43 HATCH and STE 305 941-4550 CARIBOU, ME 04736 1-800-400-6856 498-6428 1-800-400-6855 LEWISTON PORTLAND for Attorney(s) 36 MOLLISON WAY 62 ELM ST LEWISTON, ME 04240-5811 PORTLAND, ME 04101-6858 753-7700 822-0840 1-800-400-6857 1-800-400-6858 21. PREPARER NAME AND TITLE (TYPE OR PRINT): Office and P.O. Address 22. TELEPHONE NUMBER: 23. DATE: THIS DOCUMENT MAY BE PRODUCED IN ALTERNATIVE FORMATS SUCH AS BRAILLE, LARGE PRINT AND AUDIOTAPE. WCB 12 (8/94) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com