COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. SUPPLEMENTAL APPLICATION : JUDICIAL SUBPOENA SUBSIDIARY COVERAGE FOR WORKERS’ COMPENSATION SELF-INSURERS Plaintiff(s) -against- : ______________________________________________________________, a corporation duly : organized under the laws of the State of ____________________________________________, : which has previously been approved by the Industrial Commission of the State of Idaho to act as Defendant(s) : ...................................................... a workers’ compensation self-insured employer, hereby applies for extension of such authority to self-insure to the following wholly-owned subsidiary corporation(s) of such parent corporation: THE PEOPLE OF THE STATE OF NEW YORK ________________________________________________________________________ TO ________________________________________________________________________ ________________________________________________________________________ GREETINGS: ________________________________________________________________________ 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 ofIn support of such application, the applicant hereby certifies as follows: in room , on the day of , 20 , at o'clock in the noon, and at any recessed 1. or adjourned date,That the three-year average payroll of in this action on thesubsidiary corporation(s) to testify and give evidence as a witness its wholly-owned part of the is as follows: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 19____: $_______________ 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. 20____: $_______________ Witness, Honorable Court in County, $_______________ 20____: 2. day of Average: $_______________ , one of the Justices of the , 20 That it has made an additional deposit with the Idaho State Treasurer in the (Attorney must sign above and type name below) amount of $_______________, in the form of _______________________________________ equaling 5% of the average annual payroll for the wholly-owned subsidiary corporation(s) Attorney(s) for (subject to the maximum limitations set out in the regulations relating to self-insured employers), together with all outstanding and unpaid awards of compensation against such wholly-owned Office and P.O. Address subsidiary corporation(s) under the Idaho Workers’ Compensation Law. Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : 3. Index No. : Calendar have That its resident claims adjuster previously designated shallNo. full authority to : JUDICIAL SUBPOENA handle all workers’ compensation claimsPlaintiff(s) wholly-owned subsidiary corporations(s) of against the -against- : the undersigned to the same extent as if they were against the undersigned. : 4. That it agrees to assume and guarantees to pay all of the liabilities and obligations : which the wholly-owned subsidiary corporation(s) may incur under the workers’ compensation Defendant(s) : ...................................................... laws of the State of Idaho, including past, existing, future or potential claims for workers’ compensation benefits, court costs, attorney fees, or other assessments against such wholly- THE PEOPLE OF THE STATE OF NEW YORK owned subsidiary corporation(s). TO 5. In the event that an application for hearing is filed with the Industrial Commission naming such subsidiary as the employer, the undersigned does hereby agree that it can be named GREETINGS: as a party to or in lieu ofYOU, subsidiary and agrees to submit to the jurisdiction of the Idahoattend before WE COMMAND such that all business and excuses being laid aside, you and each of you , the Honorable at the Court Industrial pay all compensation awarded in the same manner that the County of Commission and to located at in room , on the day of , 20 , at o'clock in the noon, and at any recessed orsubsidiary date, to have been give evidence as a witness in this action on the part of the adjourned would testify and required to pay. 6. This agreement shall not cover or extend to any workers’ compensation liabilities Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to of such subsidiaries which are expressly insured by a carrier duly authorized to write Idaho 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. workers’ compensation insurance. Witness, Honorable , one of the Justices of the That the last annual statement of the assets and liabilities of each subsidiary for Court in County, day of , 20 7. which application is made, is attached hereto. 8. (Attorney comply with the reporting, The wholly-owned subsidiary corporation(s) shallmust sign above and type name below) claims handling, premium tax payment, and other requirements of the Idaho Workers’ Attorney(s) for Compensation Law, and the parent corporation understands and agrees that the failure of such subsidiary corporation(s) to comply with those requirements may be grounds for revocation of Office and P.O. Address the authority to extend self-insured coverage to such wholly-owned subsidiaries, as well as the self-insured status of the parent corporation. Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : 9. Index No. : Calendar requested to execute That it agrees as a condition to the granting of the authorityNo. : JUDICIAL SUBPOENA such amendments to its self-insurer’s compensation bond, and/or the power of attorney on file Plaintiff(s) -against- : with the State Treasurer’s office, as are necessary to make those documents applicable to : workers’ compensation claims against such wholly-owned subsidiary corporation(s). : 10. In the event that such subsidiary corporation(s) shall fail to pay compensation as Defendant(s) : ...................................................... compensation is defined in the Idaho Workers’ Compensation Law, when due, or the premium tax payment required by law, the undersigned shall pay the same, and payment may be enforced THE PEOPLE OF THE STATE OF NEW YORK against the undersigned to the same extent as if said payment was the direct liability of the TO undersigned. 11. GREETINGS: As provided in Idaho Code, §72-301(2), the approval by the Commission of any self-insuredCOMMAND YOU, withdrawn if it and excuses being laid aside, you and each of you attend before WE employer may be that all business shall appear to the Commission that workers , the Honorable at the Court secured are not fully protected. County of thereby under the lawlocated at 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 DATED this ____________ day of _______________________________, 20_____. 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. X______________________________________________ Witness, Honorable Court in County, , one of the Justices of the By_____________________________________________ day of , 20 ________________________________________________ Title (Attorney must sign above and type name below) STATE OF ____________________) Attorney(s) for COUNTY OF __________________) On this __________ day of ____________________, in the year 20_____, before me personally Office and P.O. Address appeared ________________________________________________________, known to me to be the person whose name is subscribed to the within instrument, and acknowledged to me that Telephone No.: he executed the same. Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal, the day and year in this certificate first above written. Plaintiff(s) -against- : JUDICIAL SUBPOENA : : : __________________________________________ Defendant(s) : ...................................................... Notary Public for ___________________________ Residing at ________________________________ THE PEOPLE OF THE STATE OF NEW YORK My commission expires on ___________________ TO GREETINGS: 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 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 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, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com