Insurers Hearing Memorandum Form. This is a Massachusetts form and can be use in Workers Comp.
Tags: Insurers Hearing Memorandum, 162, Massachusetts Workers Comp,
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : FORM 162 Index No. : Calendar No. The Commonwealth of Massachusetts : Department of Industrial Accidents JUDICIAL SUBPOENA Plaintiff(s) 600 Washington Street – 7th Floor, Boston, Massachusetts 02111 Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470 -against: http://www.mass.gov/dia Page 1 of 2 : INSURER’S : HEARING MEMORANDUM Defendant(s) TO BE COMPLETED BY COUNSEL FOR THE INSURER PRIOR TO HEARING : ...................................................... DATE: ____________________________ BOARD #: ________________________ THE PEOPLE OF THE STATE OF NEW YORK EMPLOYEE: ___________________________________________________ TO EMPLOYER: ___________________________________________________ INSURER: ___________________________________________________ GREETINGS: COUNSEL FOR INSURER: _____________________________________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before _____________________________________ , the ADDRESS: 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 COUNSEL FOR EMPLOYEE: _____________________________________ ADDRESS: _____________________________________ 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. ISSUES TO BE ADDRESSED AT HEARING (PLEASE CHECK ALL THAT APPLY): Witness, Honorablei.e., deny industrial injury , one of the Justices of the Liability, Court in County, day thereof , 20 Disability and extentof Causal relationship Deny entitlement to §36 benefits Deny entitlement to §13 & §30 benefits (Attorney must sign above and type name below) Proper notice Proper claim Deny serious & willful misconduct Attorney(s) for Other____________________________________________________________ Request Permission to Depose: Office and P.O. Address Dr. ________________________________________________________ ________________________________________________________ Telephone No.: Facsimile No.: E-Mail Address: Form 162 - Revised 8/2004 - Reproduce as needed. (over) Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Plaintiff(s) -againstISSUES TO BE ADDRESSED AT HEARING: : Index No. Calendar No. Page 2 of 2 JUDICIAL SUBPOENA : : a. Stipulations of Fact: _________________________________________________________________ ____________________________________________________________________________________ : ____________________________________________________________________________________ Defendant(s) : .____________________________________________________________________________________ ..................................................... ____________________________________________________________________________________ b. Witnesses at Hearing: 1. _________________________________________________ THE PEOPLE OF THE STATE OF NEW YORK 2. _________________________________________________ 3. _________________________________________________ 4. _________________________________________________ TO 5. _________________________________________________ GREETINGS: c. Exhibits to be Marked at Hearing: 1. that all business and excuses being laid aside, you and each of WE COMMAND YOU,_________________________________________________ you attend before , the Honorable at the Court 2. _________________________________________________ located at County of 3. _________________________________________________ in room , on the day of , 20 , at o'clock in the noon, and at any recessed 4. _________________________________________________ or adjourned date, to testify and give evidence as a witness in this action on the part of the 5. _________________________________________________ d. Medical Reports [Under 452 CMR 1.11 (6)]: 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 1. _________________________________________________ subpoena was issued for a maximum penalty of $50 and all damages sustained as a 2. result of your failure to comply. _________________________________________________ 3. _________________________________________________ Witness, Honorable 4. _________________________________________________ of the , one of the Justices Court in County, day of , 20 5. _________________________________________________ Medical Reports must be accompanied by the physician’s curriculum vitae or stipulation of qualifications. (Attorney must sign above and type name below) Will an Interpreter be Needed?: YES NO Language to be Interpreted (if applicable): Attorney(s) for NOTE: The party offering testimony by a witness who requires an interpreter must provide a certified interpreter at the time of hearing. Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com