COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. APPLICATION FOR MEDIATION OR HEARING - FORM C Michigan Department of Consumer & Industry Services : Bureau of Workers' Disability Compensation JUDICIAL Plaintiff(s) P.O. Box 30016, Lansing, MI 48909 -against- SUBPOENA : THIS FORM TO BE USED BY INSURANCE COMPANIES, SELF-INSURED EMPLOYERS AND ATTORNEYS. Submitted on behalf of : Self-insured Employer Insurance Company Street address Attorney : Name Of Employer Defendant(s) City : ...................................................... IS THIS CASE CURRENTLY IN LITIGATION? Y ES Date of Injury Employer Name NO l3ureau Other Social Security Number State Zip Code If no, please provide the following information: Federal ID Number THE PEOPLE OF THE STATE OF NEW YORK Add subsequent employer and/or dates of injury to determine liability TO 1. Name of Employer to be Added County of Injury Federal ID Number (If known) Street Address City State Zip Code GREETINGS: Dates of Injury to be Added INSURANCE CARRIER (DO NOT FILL IN) 3, 2. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before I 2. , the Honorable 2. at the Court located at County of 4. 4 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 Non-Cooperation with Vocational Rehabilitation Petition to Stop Weekly Benefits (Provide explanation below) 6. (Provide explanation below) Petition to Recoup (Provide explanation below) 7. Petition to Fix Fees (Provide explanation below) 1. 3. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 4. 5. Add Funds Petition toon whose behalf thisi.e., dependency, the party Determine Rights; subpoena was issued for a maximum penalty of $50 and all damages sustained as a 8. (Specify name of Fund and provision of Act below) AWW, etc. (Specify below) result of your failure to comply. Other Request for Rule V hearing 9. (Provide a brief explanation of the issues below) (Provide explanation below) Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) 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. Workers' Disability Compensation Act, 418.847, R408.34 Authority: Attorney(s) for Voluntary Completion: Penalty: None Name of Insurance Company or Self-Insured Employer NAIC or Self-insured Number Street Address Name of Attorney (If applicable) Office and P.O. Address Cry State Zip Code Attorney ID Number P_ Name of Preparer (Please print) BWC-104C (Rev. 10/96) Formerly Form MDL-1-104C Signature of Preparer Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Date Telephone Number American LegalNet, Inc. www.USCourtForms.com