COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. THE INDUSTRIAL COMMISSION OF ARIZONA : Calendar No. 800 WEST WASHINGTON ST. P.O. BOX 19070 PHOENIX, ARIZONA 85005-9070 : Plaintiff(s) JUDICIAL SUBPOENA -against- OPTION ELECTION FORM : FOR : WORKERS’COMPENSATION POOLS UNDER A.R.S. § 23-961.01 Part A : Defendant(s) : . .1. . . . .Please. state . . . .name . . .the .workers’ compensation .pool .filing an initial or renewal application . . . . . . . . . the . . . . of . . . . . . . . . . . . . . . . . . . . . . . . to self-insure under A.R.S. § 23-961.01. _________________________________________________________________________ THE PEOPLE OF THE STATE OF NEW YORK 2. Please select the option elected by the workers’compensation pool named in question number 1. TO Guaranty bond Bonds or securities of the United States GREETINGS: Letter of Credit WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court 3. Please state the amount of the guaranty bond, bonds or securities of the United States, or letter of located at County of credit obtained by the pool. 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 $___________________________________ which represents 125% of total outstanding accrued liability based on calculation set forth in Part B of this form (applicable only to workers’compensation pools filing a renewal application). Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to $200,000. the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Part B Witness, Honorable , one of the Justices of the 1. Please provide the following information for all workers’ compensation claims processed from Court in County, day of , 20 the pool’ initial effective date of authority to self-insure through December 31, 1998: s a. Number of claims in which medical or compensation benefits (Attorney must sign above and type name below) are currently being paid by the pool. ____________ b. Total incurred and reserved liability for medical benefits, and temporary and permanent compensation benefits Attorney(s) for (lifetime liability). $____________ c. Total amount paid to date for medical benefits, and temporary and permanent compensation benefits through last reporting Office and P.O. Address period. $____________ d. Total amount incurred, but not paid, for medical benefits, and Telephone No.: $____________ temporary and permanent compensation benefits (1b - 1c). Facsimile No.: E-Mail Address: Option Election Form Mobile Tel. No.: Page 1 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. 2. Please provide the following information for all workers’compensation claims reported in 1999: : Calendar No. a. Number of claims accepted. ____________ : JUDICIAL SUBPOENA Plaintiff(s) b. Total incurred and reserved liability for medical benefits, -against: and temporary and permanent compensation benefits (lifetime liability). $____________ : c. Total amount paid to date for medical benefits, and temporary : and permanent compensation benefits through last reporting period. $____________ Defendant(s) : ...................................................... d. Total amount incurred, but not paid, for medical benefits, and temporary and permanent compensation benefits (2b - 2c). $____________ THE PEOPLE OF THE STATE OF NEW YORK 3. Formula to determine 125% of the pool’ total outstanding accrued liability. s TO a. Total amount incurred, but not paid, for medical benefits, and temporary and permanent disability benefits for all years listed in Part B (1d + 2d). $____________ GREETINGS: b. Amount of reimbursement received from reinsurance carrier $____________ WE or carriers. YOU, that all business and excuses being laid aside, you and each of you attend before COMMAND , the Honorable at the Court Estimated future liability (3aat 3b). $____________ located County c. of in room , on the day of , 20 , at o'clock in the noon, and at any recessed d. 125 to testify outstanding accrued a witness or adjourned date, % of total and give evidence as liability in this action on the part of the ( 3c x 125%). $____________ e. Amount of bond, United States bonds or securities, and Your failure credit. court and will make you liable to letter of to comply with this subpoena is punishable as a contempt of $____________ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. I , ________________________________________________, certify under penalty of perjury, that I have authority to sign the option election form, that I am the _____________________(title) of the , one of the Justices that pool andWitness,capacity have knowledge of the information contain in the option election form,of theI in that Honorable have read the option County, form, day of election and verify that the ,representations and statements contained in the Court in 20 option election form, are true to the best of my knowledge, information, and belief. _________________________________________ (Attorney must sign above and type name below) Signature of Administrator _________________________________________ Attorney(s) for Printed or typed name of Administrator The law requires that a workers’ compensation pool obtain and maintain during all periods of self-insurance a guaranty bond, United States bonds or securities, and P.O. of credit in an amount Office or letter Address equal to the greater of $200,000 or 125% of the total outstanding accrued liability as reflected in this form. Telephone No.: Facsimile No.: E-Mail Address: Option Election Form Mobile Tel. No.: Page 2 American LegalNet, Inc. www.USCourtForms.com