COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. APPLICATION FOR APPROVAL : OF SPLIT COVERAGE Calendar No. EMPLOYEE LEASING : JUDICIAL SUBPOENA Plaintiff(s) -against- : : Pursuant to KRS 342.375, _______________________________________________ employer : ____________________________________, _________________________________ Defendant(s) : . . . . . . . . . . . . . . . . . address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FEIN ....... does hereby request authorization from the Commissioner of the Department of Workers’ Claims to secure the employer’ liability under KRS Chapter 342 through s THEseparate OF THE STATE OF NEW YORK PEOPLE insurance policies for specific plants or work locations. The applicant proposes that the principal work force of the employer, which is engaged in employee TO leasing at ___________________________________, including temporary workers, location shall be covered by _________________________________ issued by __________ GREETINGS: WC policy number Insurance WE COMMAND YOU, that all business and excuses being ___________________________. All leased employeeslaid aside, youvarious types of engaged in and each of you attend before , the Honorable at the Court Carrier located at County of in room , on the day of 20 , at o'clock in the noon, and at businesses at various locations shall be, covered by _________________________ any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Policy number issued by _____________________________. Employees in the leased work forces Your failure toInsurance Carrier 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 have distinct duties and result of your failure to comply.are not commingled. This the _______day of __________________, 20___. , one of the Justices of the Witness, Honorable Court in County, day of , 20 _____________________________________ (Attorney must sign Employer Representative Ofabove and type name below) Subscribed and sworn to before me, this the _____day of _______________, 20 ___. Attorney(s) for _____________________________________ Notary Public Office and P.O. Address My Commission expires _______________________; County ____________ Form .375 EL Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com