COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. APPLICATION FOR APPROVAL : JUDICIAL SUBPOENA Plaintiff(s) OF SPLIT COVERAGE -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 TO _______________________ at _______________________________ shall be covered type of business location(s) by __________________________________. A separate work force engaged in ____ GREETINGS:insurance carrier WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before _________________located at ____________________________________________ , the Honorable business at the location(s) Court type of located at County of shall by _______ in room be coveredthe ______________________________________issued noon, and at any recessed , on by day of , 20 , at o'clock in the or adjourned date, to testify and give evidence as anumber in this action on the part of the policy witness ________________________. Employees in the separate work forces have distinct Your failure to commingled. duties and are notcomply 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. This the ______day of ____________, 20____. Witness, Honorable Court in County, , one of the Justices of the day of , 20 _____________________________________ Representative of Employer (Attorney must sign above and type name below) Subscribed and sworn to before me, this the _______day of ______________, 20___. Attorney(s) for _____________________________________ Notary Public My commission expires ________________________; County____________________ Office and P.O. Address FORM .375 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com