COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. Calendar No. REQUEST FOR CONSULTATIVE RATING State of California Division of Workers' Compensation Disability Evaluation Unit : : Plaintiff(s) JUDICIAL SUBPOENA DEU Use Only Indicate type of request: -against- Mail-in Walk-in : : INSTRUCTIONS FOR MAIL-IN'S: : 1. Enclose pre-addressed envelopes for yourself and the opposing party. 2. Attach a photocopy of the medical report(s) for which a rating is being requested. Do not send original reports. Defendant(s) : . . . . . . . . . . . . to the DEU . . . . . . . . . . the WCAB . . . . . . 3.. . Send .this. request . . . . . . . . . . office. serving . . . . . . . . . .location .in which the case has been filed. 4. Serve a copy of this request on the representative for the opposing party. INSTRUCTIONS FOR WALK-IN'S: THE PEOPLE OF THE STATE OF NEW YORK 1. Place report(s) to be rated on top of the WCAB file, unless report has been placed into evidence. 2.TO report(s) have been placed into evidence, clearly mark them with a paper clip or post-it note. If 3. If a deposition is to be rated, mark or list the pages to be reviewed by the rater. GREETINGS: Injured worker's name WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before WCAB case number(s) , the Honorable at the Court located County of (attach description if unclear) at Occupation in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testifyDate give evidence as a witness in this action on the part of the and of injury Date of birth Social security number Your failure to comply with this subpoena is punishable as a contempt 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 Insurance claim result of your failure to comply. number Date of report(s) to be rated and doctor's name: Witness, Honorable , one of the Justices of the , 20 Court in / County, / / / / / day of (Attorney must sign above and type name below) This case has been set for: hearing conference Attorney(s) for msc on rating pre-trial / / . Office and P.O. Address Rating requested by: name of firm representing the A copy of this request has been served on Consult Request Form (Rev. Jan. 2003) Telephone No.: Facsimile No.: name of firm E-Mail Address: Mobile Tel. No.: employee employer . American LegalNet, Inc. www.USCourtForms.com