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Statement Of Proposed Stipulations And Notice Of Contested Issues (Injury) Form. This is a Kentucky form and can be use in Workers Comp.
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Tags: Statement Of Proposed Stipulations And Notice Of Contested Issues (Injury), Kentucky Workers Comp,
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Plaintiff(s)
Calendar No.
:
JUDICIAL SUBPOENA INJURY
COMMONWEALTH OF KENTUCKY
-against:
DEPARTMENT OF WORKERS CLAIMS
CLAIM NO(S). _____________________
:
BEFORE ALJ __________________________
_____________________________________________
Defendant(s)
:
PLAINTIFF
:
VS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
_____________________________________________
_____________________________________________
THE PEOPLE OF THE STATE OF NEW YORK
TO
DEFENDANT(S)
STATEMENT OF PROPOSED STIPULATIONS
AND
NOTICE OF CONTESTED ISSUES
GREETINGS:* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
**
I.
1.
2.
3.
4.
5.
6.
STIPULATIONS
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorableunder the Act.
at the
Court
Coverage
located at
County of
at all relevant times.
inAn employment relationship existed between the, employee and in the
room
, on the
day of
, 20
at
o'clock employernoon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Employee sustained a work-related injury(ies) on ____________________________________
The employer received due and timely notice of employee's injury(ies).
Your average weekly wage.
Employee'sfailure 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
Temporary total comply.
result of your failure todisability benefits were paid at the rate of $___________ per week from
_____________________ through _______________________, for a total of $___________.
7.
8.
Witness, Honorable
Court in
County,
, one of the Justices of the
The employer has paid a total of $___________ for medical expenses as a result of this injury.
day of
, 20
The following medical expenses are in dispute:
Medical provider
Service
Date
Amount
Nature of Dispute
(Attorney must sign above and type name below)
Attorney(s) for
9.
Employee _______ has _______ has not returned to work. P.O. Address
Office and
10.
Employee's current weekly wage is $_____________________________________________
11.
Employee _______ does _______ does not retain physicalNo.:
Telephone capacity to perform the type of
Facsimile No.:
E-Mail Address:
_____________________________________________________
Mobile Tel. No.:
work he did at date of injury.
12.
Employee's date of birth:
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
Index No.
Calendar No.
13.
Employee's educational level:
________________________________________________
14.
JUDICIAL SUBPOENA
Employee's specialized or vocational training: _____________________________________
Plaintiff(s)
15.
Other matters:
:
-against:
___________________________________________________________
___________________________________________________________________________
:
___________________________________________________________________________
:
___________________________________________________________________________
Defendant(s)
:
......................................................
II.
CONTESTED ISSUES
The following THE STATE OF NEW YORK
THE PEOPLE OF issues are contested:
1.
2.
___________________________________________________________________________
TO
___________________________________________________________________________
3.
___________________________________________________________________________
4.
GREETINGS:
___________________________________________________________________________
5.
___________________________________________________________________________
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
County of
*************************************************
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
PLEASE NOTE:
1.
2.
All matters not in controversy should be stipulated.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
The issues listed above subpoena was issued for a maximum penalty Law and all
the party on whose behalf this will be considered by the Administrativeof $50 Judge.damages sustained as a
result of your failure to comply.
This the _______ day of ______________________________, one of the Justices of the
Witness, Honorable
, 200___.
Court in
County,
day of
, 20
__________________________________________
Attorney
(Attorney must sign above and type name below)
Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
Revised: 12/12/01
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