COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : FORM 110-(CWP) Plaintiff(s) Calendar No. : JUDICIAL SUBPOENA Revised: 7/02 KENTUCKY DEPARTMENT OF WORKERS’ CLAIMS -against: Frankfort, KY 40601 : AGREEMENT AS TO COMPENSATION AND ORDER APPROVING SETTLEMENT Workers’ Compensation Claim No. ____________________ : IF THIS FORM IS NOT PROPERLY COMPLETED, IT WILL BE RETURNED. Defendant(s) : . . . . . . . . . . Every. section. should .be.filled. in. . If .a. section.is .not . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . applicable, fill in the blank with N/A. Claimant Insurer/Self-Insured/Self-Insurance Group THE PEOPLE OF THE STATE OF NEW YORK Social Security Number Date of Birth Insurer’s Address TO Address City, State Zip Code City, State, Zip Code GREETINGS: Employer Other party WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Address Address , the Honorable at the Court located at County of Zip Code City, State, City, State, Zip Code 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 COAL WORKERS’ PNEUMOCONIOSIS: INJURIOUS EXPOSURE Cause of disease: Length of exposure: __________________________ Date ofYour exposure:comply with this subpoena isin which exposure occurred: last failure to County 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. description of history of exposure to coal dust: Brief Witness, Honorable Court in County, , one of the Justices of the day of , 20 MEDICAL INFORMATION Medical expenses paid: $ Medical expenses unpaid or contested: $ Surgery performed: Yes No Hospitalization(s): Yes No Date of last medical payment: (Attorney must sign above and type name below) Nature of surgery: Length of hospital stay(s): Attorney(s) for X-ray interpretations by B-readers: (Attach entire x-ray interpretation report) ILO Classification _______________ _______________ _______________ _______________ _______________ Date of Report ________________ ________________ ________________ ________________ ________________ 1 Physician ______________________________ ______________________________ Office and P.O. Address ______________________________ ______________________________ ______________________________ Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : Has the Commissioner’s Notice of Consensus been issued? _______Yes _______No JUDICIAL SUBPOENA Plaintiff(s) If yes, specify the consensus finding and attach a copy of the notice: ___________________ -against: ______________________________________________________________________________ : Pulmonary function studies: (Attach entire medical report that provides ratings) FVC/FEV1 Date of Study :Physician ______________________________ Defendant(s) :______________________________ ...................................................... __________________ ________________ ______________________________ ______________________________________________________________________________ Diagnosis: __________________________________________________________________ THE PEOPLE OF THE STATE OF NEW YORK If medical treatment is continuing, attach a copy of executed Form 113 indicating designated TO physician. WORK INFORMATION Type of work GREETINGS: at last exposure: ____________________________________________________ Average weekly wage at time of last exposure: WE COMMAND YOU, that all business and ________________________________________excuses being laid aside, you and each of you attend before , the Honorable performed at time of settlement: ________________________________________ at the Court Type of work located at County of in room , on the day AND SETTLEMENT INFORMATION , 20 , at o'clock in the noon, and at any recessed BENEFITof or adjourned date, to testify and give evidence as a witness in this action on the part of the Monetary terms of settlement: $ , to be paid as follows: ___ lump sum , ___ weekly for weeks, ____ by annuity, ___ other Total settlement amount: $ Percent of permanent disability: % Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Settlement computation: the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Does your failure to comply. past or future medical result ofsettlement amount include waiver or buyout of expenses? Yes No. If yes, settlement amount for waiver or buyout: $ Witness, Honorable , one of the Justices of the If settlement terms provide for lump sum representing weekly benefits greater than $100, does Court in County, day of , 20 Yes No claimant have an adequate source of income during disability? Source of income: Amount: $ Does settlement include retraining incentive benefits? Yes No (Attorney must sign If yes, is claimant enrolled and actively and successfully participating in above and fidename below) a bona type training or education program approved by the Commissioner? Yes No Name of training or education program (Attach additional pages if necessary): Attorney(s) for OTHER INFORMATION If additional information is pertinent to settlement, explain, (Attach additional pages if necessary): Office and P.O. Address ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. : CERTIFICATION OF PARTIES JUDICIAL SUBPOENA Plaintiff(s) By signing this agreement, the parties and their representatives hereby certify that all sums -against: paid pursuant to this agreement are in settlement of the plaintiff’s coal workers’ pneumoconiosis claim only and no sums have been included for any other claims or potential claims the plaintiff has : against the defendant-employer. : This the day of , 20 Defendant(s) : ...................................................... Attorney or representative for claimant (Signature) . Claimant (Signature) Attorney or representative for claimant (Name typed) Attorney or representative for employer Address Address City, State, Zip City, State, Zip 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 COAL WORKERS PNEUMOCONIOSIS County of ORDER APPROVING in room , on the daySETTLEMENT AGREEMENT 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 IT IS ORDERED that the above Agreement as to Compensation be and the same is hereby APPROVED. 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. of day , 20 . This the Witness, Honorable Court in County, , one of the Justices of the Administrative Law Judge , 20 day of (Attorney written above and participation with Pursuant to 803 KAR 25:009E, Section 27, the employer is required to file amust signrequest fortype name below) the Kentucky Coal Workers’ Pneumoconiosis Fund within 30 days of the Order Approving Settlement Agreement. Attorney(s) for Office and P.O. Address 3 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com