See instructions on reverse side before completing form COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION DEPENDENT'S NOTICE AND CLAIM FOR COMPENSATION Social Security # City Male Female Employee's home phone # State Zip code Division Use Only SOI POB NOI Coder Employee's name (first, middle, last) Employee's street address Birth date COURT Marital status Dependents Date of hire Occupation Employment status COUNTY .OF. . . . Married . . . . Separated. . . . . Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Full time Part time .... . .. . ... / / / / Single Unknown No Other Unknown : Index No. Employer's name (Company) Employer's phone # : Employer's mailing address Average Weekly Wage A. B. City Calendar No. State Zip code Plaintiff(s) -againstCalculate the average weekly wage. Multiply the average number of hours worked per week, excluding overtime, times the hourly wage--see instructions Check box if employee received : : JUDICIAL SUBPOENA : Subtotal (A) $ : Provide the average weekly value of the benefit Overtime $ Defendant(s) : Tips (amount reported .to .IRS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ . . ... Commissions $ Piecework $ Mileage (if a form of salary) $ THE Other (room, board, etc.) PEOPLE OF THE STATE OF NEW YORK $ Health Insurance (see instructions) $ Subtotal (B) $ TO C. Add subtotals A & B Date of death / = GREETINGS: Average weekly wage at time of injury (C) $ Date of injury/disease / / (See instructions) Date employer notified Last date worked Injury time ____ ____ a.m. / / / / / ____ ____ p.m. Unknown WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Time employee began work ____ ____ a.m. ____ ____ p.m. 1 at the Court What type of injury did the employee receive? the Which part of body was affected?Honorable , located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed 2 What was the employee doing just before the accident occurred? or adjourned date, to testify and give evidence as a witness in this action on the part of the 3 How did the injury occur? What object or substance directly harmed the employee? 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 result of your failure to comply. 4 Name and phone # of witness To whom,was it reported? 20 ( ) Witness, Honorable Where did the accident occur? (street address, city, state, and county) of Court in County, day , one of the Justices of the Initial treatment (check one) None Emergency room Hospital stay over 24 hrs Minor must sign above and type nameClinic/Hospital below) (Attorney on-site Name and address of treating doctor or other health care professional Name and address of facility where treated Attorney(s) for If death resulted from an occupational disease (i.e.,silicosis, asbestosis, anthracosis, etc.) give names of employers where the exposure occurred and dates of employment (attach additional sheet if needed). / / to Office and Dates of employment P.O. Address / / to Dates of employment For Division Use Only Facsimile No.: Carrier claimE-Mail Address: # Adjuster Code Mobile Tel. No.: Page 1 of 3 Block # American LegalNet, Inc. www.USCourtForms.com / / / / Employer Employer Telephone No.: FEIN Policy # WC18 Rev 04/06 1. 2. 3. 4. Name of Mortuary Address Amount of funeral expenses Has same been paid? If so, by whom? Yes No Was employee married on the dateCOURT of the injury? If married, provide: COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : a. Full name of surviving spouse Index No. b. c. d. e. Present address and phone # of surviving spouse Was surviving spouse living with employee at the time of death? Social Security # of spouse Birth date of spouse Plaintiff(s) : Yes : : Calendar No. No ( ) JUDICIAL SUBPOENA / -against/ Yes No 5. Was employee previously married? If so, provide name and address of former spouse(s) : : 6. Provide name, date of birth, SS #, and present address of all children of the employee under the age of eighteen (18) years: Defendant(s) : . .... . ... .. Name. . . . . . . . . . . . . . . . . . Date .of .Birth. . . . . . . . . . . .SS. # . . . . . . . . . . Address / / / / / / / / THE PEOPLE OF THE STATE OF NEW YORK TO 7. Provide name, date of birth, SS #, and present address of any child of the employee over the age of eighteen (18) and under the age of twenty-one (21)who was dependent upon the employee for support and was a full-time student at an accredited school at the time GREETINGS: of employee's death: Date of Birth SS # Address WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court / / located at County of / /day of in room , on the , 20 , at o'clock in the noon, and at any recessed or adjourned date, present occupation, relationship witness in this and present part of of Provide name, date of birth, SS #, to testify and give evidence as a to the employeeaction on the address theany other person who was wholly or partially supported by the employee at the time of employee's death: Relationship Present Address Name Date of Birth SS # Occupation to Employee 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 result of your/ failure to comply. / Other than amounts received from the employee, what income did each of the dependents listed in #8 receive, during the year Witness, Honorable , one of the Justices of the immediately preceding the death of the employee? Court of County, , 20 Indicate whether eachin the dependents listed in #8 day of was incapable or actually disabled from earning his/her own living, and if so, for what period of time. (Attorney must sign above and type name below) Name 8. 9. 10 . Attach a copy of employee's marriage certificate(s), death certificate, and children's birth certificates. State of Colorado, ss. { Attorney(s) for Affidavit of Claimant County of foregoing notice and claim are true. being first duly sworn upon oath deposes and says, that the statements made in the Office and P.O. Address (Si