COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : APPLICATION FOR MEDIATION OR HEARING - FORM Calendar No. A Michigan Department of Consumer & Industry Services Bureau of Workers' & Unemployment Compensation Plaintiff(s) P.O. Box 30016, Lansing, MI 48909 -against- : APPLICATION TYPE JUDICIAL SUBPOENAOnly Initial Penalty Amended : VR Only THIS FORM TO BE USED BY EMPLOYEES ONLY A SEPARATE BWC-104A MUST BE FILED FOR EACH EMPLOYER. INCOMPLETE APPLICATIONS SHALL BE RETURNED. : 1. NAME OF EMPLOYEE (Last, First, MI) 2. SOCIAL SECURITY NUMBER 4. STREET NUMBER AND NAME 8. TAX FILING STATUS 5. CITY 3. DATE OF BIRTH : A. Single Defendant(s) : 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . STATE . . . 7.. ZIP .CODE . . . . . . . . . . B. Single, Head . .. .... C. Married, Filing Joint D. Married, Filing Separate of Household 10. DATE OF DEATH (If Applicable) 9. SEX Female Male 11. NAME OF DEPENDENTS 12. RELATIONSHIP TO EMPLOYEE THE PEOPLE OF THE STATE OF NEW YORK 13. BIRTHDATE TO GREETINGS: 20. DATES OF EMPLOYMENT 14. NAME OF EMPLOYER WE COMMAND YOU, that all business and excuses FROM: laid aside, you and each of you attend before being TO: , the Honorable at the 21. EARNINGS Court 15. FEDERAL I.D. NUMBER (If Known) located at County of HOURLY/WEEKILY $ 22. CITY OF INJURY 16. STREET ADDRESS 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 18. STATE 17. CITY 19. ZIP CODE 23. COUNTY OF INJURY DURATION OF DISABLEMENT 24. DATE(S) OF INJURY INSURANCE CARRIER FROM TO Your failure to comply with this subpoena is punishable as a contempt of (DO NOT FILLwill make you liable to court and IN) 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. Court in Witness, Honorable County, , one of the Justices of the day of , 20 25. DESCRIBE THE NATURE OF THE DISABILITY AND THE MANNER IN WHICH THE INJURY OR DISABLEMENT OCCURRED, AND SPECIFY THE RELIEF SOUGHT. (Attorney must sign above and type name below) YES 26. DID THE EMPLOYEE HAVE ANY OTHER EMPLOYMENT AT THE TIME OF THE INJURY? IF YES, LIST NAME AND ADDRESS OF THE EMPLOYER AND GROSS WEEKLY WAGE. NO Attorney(s) for YES NO YES HAS A CLAIM BEEN FILED WITH THIS SECOND EMPLOYER? 27. HAS THE EMPLOYEE HAD ANY EMPLOYMENT SINCE THE DATE OF INJURY? NO IF YES, LIST THE NAME AND ADDRESS OF THE EMPLOYER. Office and P.O. Address YES 28. DOES THIS APPLICATION INVOLVE A DISPUTED CLAIM FOR MEDICAL BENEFITS? NO IF YES, GIVE APPROXIMATE AMOUNT. 29. DOES THIS APPLICATION INVOLVE A DISPUTED CLAIM FOR WAGE LOSS BENEFITS? IF YES, HAS THE DISABILITY NOW ENDED? 30. HAS THE EMPLOYEE RETURNED TO WORK? IF YES, DATE OF RETURN BWC-104A (Rev. 9/02) FRONT (Formerly MDL-104A) / / Telephone No.: YES Facsimile No.: YES E-Mail Address: YES Mobile Tel. No.: NO NO NO American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. 31. IS THIS A CASE IN WHICH WAGE LOSS BENEFITS WERE PAID VOLUNTARILY AND HAVE BEEN TERMINATED WITHIN THE LAST 60 DAYS? 32. DOES THIS INVOLVE A CLAIM FOR VOCATIONAL REHABILITATION SERVICES? -against- IF YES, PLEASE SPECIFY THE NAME OF THE FUND AND THE SPECIFIC PROVISION OF THE ACT NO NO YES NO JUDICIAL SUBPOENA : 33. IS A CLAIM BEING MADE AGAINST ONE OF THE FUNDS? YES YES : Plaintiff(s) : : 34. OTHER BENEFITS Defendant(s) ...................................................... : (Please indicate which of the following benefits you are or have received based on employment with this employer during the periods of disability indicated on this application) A. OLD AGE SOCIAL SECURITY B. PENSION OR RETIREMENT PLAN C. SICK AND ACCIDENT INSURANCE D. WEEKLY/MONTHLY WAGE CONTINUATION PLAN E. UNEMPLOYMENT BENEFITS WEEKLY/MONTHLY F. DISABILITY INSURANCE POLICY WEEKLY/MONTHLY WEEKLY/MONTHLY G. SELF INSURANCE PLAN WEEKLY/MONTHLY WEEKLY/MONTHLY H. PROFIT SHARING PLAN WEEKLY/MONTHLY WEEKLY/MONTHLY THE PEOPLE OF THE STATE OF NEW YORK TO 35. LIST THE NAMES AND ADDRESSES OF DOCTORS, HOSPITALS, AND OTHER HEALTH CARE PROVIDERS WHO TREATED YOU FOR A PERSONAL INJURY GREETINGS: NAME ADDRESS (Street Number and Name) CITY STATE ZIP CODE 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,OF ANY WITNESSES. evidence as a witness in who are currentlyon the part of theemployer) to testify and give (Do not list names of witnesses this action employed by the named 36. LIST THE NAMES AND ADDRESSES NAME ADDRESS (Street Number and Name) CITY STATE ZIP CODE 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. YES 37. I INTEND TO CALL WITNESSES WHO ARE CURRENTLY EMPLOYED BY THE NAMED EMPLOYER. Witness, Honorable Court in County, day of Making a false or fraudulent statement for the purpose of obtaining or denying benefits can result in criminal or civil prosecution, or both, and denial of benefits. , one of the Justices of the NO , 20 AUTHORITY: Workers' Disability Compensation Act, 418.222; 418.847; R 408.34 COMPLETION: Voluntary PENALTY: None (Attorney must sign above and type name below) CERTIFICATION AND SIGNATURE I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE. I ALSO CERTIFY THAT I HAVE, AS OF THIS DATE, MAILED TO MY EMPLOYER OR ITS INSURANCE CARRIER COPIES OF ANY MEDICAL RECORDS RELEVANT TO THIS CLAIM THAT ARE IN MY POSSESSION. SIGNATURE OF APPLICANT Attorney(s) TELEPHONE NUMBER ( for DATE ) ATTORNEY IDENTIFICATION NAME OF ATTORNEY NAME OF LAW FIRM ATTORNEY I.D. Office and P.O. Address P. I ADDRESS (Street Number and Name) CITY SIGNATURE OF ATTORNEY TELEPHONE NUMBER No.: Telephone ( STATE ZIP CODE DATE ) Facsimile No.: E-Mail Address: Mobile Tel. No.: BWC-104A (Rev. 9/02) BACK American LegalNet, Inc. www.USCourtForms.com