COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : WORKER'S COMPENSATION BOARD OF INDIANA 402 West Washington Street, Room Plaintiff(s) W196 Indianapolis, IN 46204 -againstwww.in.gov/workcomp Index No. Calendar No. : : JUDICIAL SUBPOENA (Revised 2003) FORM SI-3 : WORKER'S COMPENSATION AND OCCUPATIONAL DISEASES ACTS CERTIFICATE OF EXCESS INSURANCE : This certifies that a Worker's Compensation and Occupational diseases Excess Insurance Policy has been issued Defendant(s) and delivered to the Employer named below, : . .and . that. .by. .issuance. .and. .delivery. .of. .the . said. .policy and the filing of this ... .... . ........ .. ........ . ... .... .. certificate of insurance, it is admitted that said excess policy was effective on the date stated below and that the coverage provided therein is applicable to benefits under the Worker's Compensation Act and the THE PEOPLE OF THE STATE OF NEW YORK Occupational Diseases Act of the State of Indiana and that said policy shall remain in full force and effect until thirty (30) days after receipt by the Worker's Compensation Board of notice of its cancellation. TO NAME OF INSURED EMPLOYER:______________________________________________ GREETINGS: ADDRESS: ______________________________________________________________ NAME OF INSURER: ______________________________________________________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before ADDRESS: , the Honorable______________________________________________________________ at the Court located at County of NAME OF AUTHORIZED AGENT: _____________________________________________ in room , on the day of , 20 , at o'clock in the noon, and at any recessed orADDRESS: date, to testify and give evidence as a witness in this action on the part of the adjourned ______________________________________________________________ TELEPHONE NUMBER: ____________________________________________________ Your OF AUTHORIZED AGENT: ________________________________________ SIGNATURE 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 POLICY NUMBER: ____________________________ result of your failure to comply. Witness, Honorable Court in of the policy is attached to this, 20 County, day of A copy certificate. EFFECTIVE DATE: ____________________EXPIRATION DATE: __________________ , one of the Justices of the FORM OF COVERAGE: Specific Excess________________ Aggregate Excess_____ (Attorney must sign above and type name POLICY LIMITS: ___________________________________________________below) SELF-INSURED RETENTION: __________________________________________ It is specifically understood and agreed to byAttorney(s) for insurance carrier the excess that this excess policy is issued for the purpose of inducing the Worker's Compensation Board of Indiana to approve the Self-Insurance application of the employer herein named and covered by this policy. N0TE: This excess insurance coverage shall be Office and P.O. Address compensation for both worker's and occupational diseases unless otherwise specifically designated herein and the express approval of the Board is specifically endorsed hereon. Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com