COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : INSTRUCTIONS : Plaintiff(s) -against- Index No. Calendar No. JUDICIAL SUBPOENA : Every FATAL, PERMANENT TOTAL AND PERMANENT PARTIAL case on which compensation : is being paid by your company, must be entered on this form and carried forward on subsequent reports until paid out. New cases will be entered as they are determined and carried forward on the next report. (Be sure to disregard all Total Temporary cases.) : File report by the 10th of the month. Defendant(s) : . . . . . HEADING:. . .PRINT. NAME. OF .INSURER.OR.SELF-INSURED. EMPLOYER, YEAR AND SELECT ........ .... ..... .. ....... .. ............ CALENDAR ENDING QUARTER. COLUMN 1. DATE OF INJURY THE PEOPLE OF THE STATE OF NEW YORK COLUMN 2. NAME OF INJURED EMPLOYEE TO COLUMN 3. CLASS OF DISABILITY Enter in this column the kind of case; i.e., FATAL, PERMANENT TOTAL, OR PERMANENT PARTIAL. (Use Abbreviations) GREETINGS: 4. TOTAL AWARDS COLUMN Include total compensation and other expenses as shown on the approved Summary of WE COMMAND YOU, Reservesbusiness and excuses being laid aside, you and each of you attend before Payments and/or that all established for Permanent Totals. , the Honorable at the Court COLUMN 5. COMPENSATION PAID located at County of Enter the in room , on the amount paid on each case since the ,last report was filed. in the day of , 20 at o'clock noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the COLUMN 6. TOTAL COMPENSATION PAID Enter the total amount paid on the award, including amount shown in column 5. COLUMN 7. ADJUSTMENT Your failure to all adjustmentsthis changes of conditions, remarriage, deaths, errors, etc. in this make you liable to Make comply with for subpoena is punishable as a contempt of court and will the party on whose behalf this subpoena are made, then column 4 must equal column$50 and all damages sustained as a Column. If adjustments was issued for a maximum penalty of 6 plus column 7 result of your failure tocolumn 8. Plus comply. COLUMN 8. UNPAID BALANCE Witness, Honorable This will show the balance due on each case. Court in County, day of , one of the Justices of the , 20 THIS FORM MUST BE COMPLETED AND EXECUTED DIRECTLY BY THE SURETY OR (Attorney must sign above and type name below) SELF-INSURED EMPLOYER MAIL TO: IDAHO INDUSTRIAL COMMISSION FISCAL SECTION P. O. BOX 83720 BOISE, ID 83720-0041 Attorney(s) for PHYSICAL ADDRESS: IDAHO INDUSTRIAL COMMISSION Office and P.O. Address FISCAL SECTION 317 MAIN STREET BOISE, ID 83702 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com : ...................................................... IC 36, REPORT OF OUTSTANDING AWARDS FOR FATAL, PERMANENT PARTIAL THE PEOPLE OF THE STATE OF NEW YORK IMPAIRMENT, AND PERMANENT TOTAL DISABILITY CLAIMS TO (Name of Insurer or Self-Insured Employer) GREETINGS: Year: __________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before March June at the September CourtDecember , located at County of (3) (4) (5) , 20 (8) in room , on the day of , at (6) o'clock in the (7) noon, and at any recessed Type date, to testify and give evidence as a witness in this action on the part of the Total Compensation Total Adjustment Unpaid or adjourned For CalendarHonorable the Quarter Ending: (1) Date Of Injury (2) Claimant Name (as shown on First Report of Injury) of Claim Awards on this Report Compensation Paid Balance 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. Witness, Honorable Court in County, Total , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Send Original to: Fiscal Section, Industrial Commission, P.O. Box 83720, Boise, Idaho 83720-0041 Attorney(s) for _________________________________________________________________________________________________________ Corporate Officer’s Signature and Title PrintedOffice and P.O. Address Name Date: __________________________ Print Name and Title of Preparer: ______________________________ Telephone No.: Company: ____________________________________________ Facsimile No.: Address: _____________________________________________ E-Mail Address: Telephone: ___________________________________________ Page ________ of _________ Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com