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Statement Of Proposed Stipulations And Notice Of Contested Issues (Occupational Disease) 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 (Occupational Disease), Kentucky Workers Comp,
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
Index No.
Calendar No.
O.D.
:
COMMONWEALTH OF KENTUCKY
JUDICIAL SUBPOENA
Plaintiff(s)
DEPARTMENT OF WORKERS CLAIMS
-against- NO(S). _____________________
:
CLAIM
BEFORE ALJ __________________________
:
_____________________________________________
VS.
PLAINTIFF
:
Defendant(s)
:
......................................................
_____________________________________________
_____________________________________________
DEFENDANT(S)
THE PEOPLE OF THE STATE OF NEW YORK
STATEMENT OF PROPOSED STIPULATIONS
AND
NOTICE OF CONTESTED ISSUES
TO
*************************************************
I.
STIPULATIONS
GREETINGS:
1.
2.
3.
WE under the Act.
Coverage COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
The of
timely notice of the employee's claim.
County employer had due andlocated at
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
Employee's average weekly wage.
or adjourned date, to testify and give evidence as a witness in this action on the part of the
4.
Employee's last date of exposure:
5.
Employee's was last exposed to the hazards of the disease while employed by this employer.
6.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
Employee had behalf this subpoena exposure.
the party on whose _______ years of was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
Employee had ______ single or ______ multiple exposure.
7.
8.
Employee's date of birth:
Witness, Honorable
___________________________________________
_____________________________________________________
, one of the Justices of the
9.
Court in
County,
day
, 20
Employee's educational level: of________________________________________________
10.
Employee's specialized or vocational training: _____________________________________
11.
The following medical expenses are in dispute:
Medical provider
Service
Date
(Attorney must sign above and type name below)
Amount
Attorney(s) for
Nature of Dispute
Office and P.O. Address
12.
Other matters:
Telephone No.:
___________________________________________________________
Facsimile No.:
___________________________________________________________________________
E-Mail Address:
Mobile Tel. No.:
___________________________________________________________________________
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
II.
Index No.
Calendar No.
CONTESTED ISSUES
The following issues are contested: Plaintiff(s)
-against-
:
JUDICIAL SUBPOENA
:
1.
___________________________________________________________________________
2.
:
___________________________________________________________________________
3.
___________________________________________________________________________
:
4.
___________________________________________________________________________
Defendant(s)
:
......................................................
5.
___________________________________________________________________________
* * * * * * * * * OF * * * * * * *
THE PEOPLE*OF*THE*STATE * * *NEW YORK * * * * * * * * * * * * * * * * * * * * * * * * * * *
PLEASE NOTE:
TO
1.
2.
All matters not in controversy should be stipulated.
The issues listed above will be considered by the Administrative Law Judge.
GREETINGS:
WE COMMAND of ______________________________, 200___.
This the _______ dayYOU, 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
Attorney
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.
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
(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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