COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. Notice of Claim Denial or Acceptance Form 111- Injury and Hearing Loss Adopted 1/1/97 Filed: : Calendar No. COMMONWEALTH OF KENTUCKY DEPARTMENT OF WORKERS CLAIMS : JUDICIAL SUBPOENA Plaintiff(s) Before Arbitrator -against-Number : Claim NOTICE OF CLAIM DENIAL OR ACCEPTANCE : Do Not Write In This Space : Defendant(s) : ...................................................... Plaintiff/Employee vs. THE PEOPLE OF THE STATE OF NEW YORK Defendant/Employer TO , as insured by Comes the defendant, response to the Application for Resolution of Claim, states as follows: , and in 1. This claim is accepted as compensable in its entirety. A settlement agreement will be GREETINGS: filed. (Note: if claim is accepted, do not complete paragraphs 2 - 7). WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the 2. This claim is accepted as compensable, but there is a Court concerning dispute located at County of the amount of compensation owed to the plaintiff. in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned This claim is denied for the following reasons: action on the part of the 3. date, to testify and give evidence as a witness in this (a) Plaintiff was not employed by defendant on the date of alleged injury. Explain: 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 (b) to comply. result of your failure The alleged injury did not arise out of and in the course of employment. Explain: Witness, Honorable , one of the Justices of the (c) The plaintiff did not give due and20 timely notice to employer of the injury. Court in County, day of , Explain: (d) The claim is barred by limitations. Explain: Other reason for denial. Explain: (Attorney must sign above and type name below) Attorney(s) for 4. The plaintiff's average weekly wage at the time of the alleged injury was $ . Completed AWW-1 to support this calculation is attached, if amount is different from plaintiff's Office and P.O. Address application for resolution. 5. The following witnesses may present testimony relevant to denial of this claim. Telephone No.: 1. Facsimile No.: 2. E-Mail Address: 3. Mobile Tel. No.: 4. American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : 6. Index No. The following are admitted by the employer: : Calendar No. Yes No Plaintiff's injury was covered under the Workers Compensation Act. : Plaintiff(s) JUDICIAL SUBPOENA The injury occurred or became disabling on ____________, 200___ -against: Date Plaintiff gave due and timely notice of the: injury. Plaintiff has returned to work for this employer and is earning $_______ per week. : Defendant(s) : Temporary total disability income benefits were paid as the result of the injury. ...................................................... All known medical expenses have been paid as the result of the injury. PEOPLE OF THE the physical requirements 7. THE Describe in detail STATE OF NEW YORK of plaintiff's job at the time of the alleged injury. If an official job description exists, a copy must be attached. TO 8. The following persons have gathered information for completion of this form. For the employer: GREETINGS: Name Title WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Address: Street , the Honorable at the Court located at County of State in room , on the City day of , 20 , at Zip Code 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 ( Telephone Number For the insurance carrier: failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Your Name Title 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. Address: Witness, Honorable City Court in County, Street day of State , 20 Zip Code , one of the Justices of the ( ) Telephone Number Being duly sworn, the undersigned states that the statements in this form are true and correct to the best (Attorney must sign above and type name below) day of , 200 . of my knowledge and belief. This the Signature Title Attorney(s) for Address Phone Number Subscribed and sworn to before me this My commission expires: County: day of Office and200 Address , P.O. Telephone Notary Public No.: Prepared and submitted by: Representative/Title Address Facsimile No.: E-Mail Address: Mobile Tel. No.: Phone Number American LegalNet, Inc. www.USCourtForms.com