COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : DEATH BENEFIT STIPULATION Index No. Department of Workforce Development : -against- Calendar : Plaintiff(s) JUDICIAL SUBPOENA : Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(l)(m)]. Deceased Employee Name WC Claim Number Injury Date : : Employee Social Security Number Applicant.Mailing.Address . . .... ..... Worker's Compensation Division 201 E. Washington Ave., Rm. C100 No. Box 7901 P.O. Madison, Wl 53707-7901 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://www.dwd.state.wi.us/wc/ e-mail: DWDDWC@dwd.state.wi.us Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City. . . . . .. State Zip Code City State Zip Code City State Zip Code Employer Name THE PEOPLE OF THE STATE OF NEW YORK Employer Mailing Address TO Insurance Company Name insurance Company Mailing Address GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before vs. , the Honorable at the Respondent Court Applicant 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 Insurance Company The parties stipulate the following facts for a Department of Workforce Development award: Date respondent employer and employee were subject Your failure to comply to Wisconsin Worker's Compensation Act: with this subpoena Date of Employee Death 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 Total Earnings for Year Prior to Injury Compensation Paid Average Weekly Wage result of your failure to comply. $ Death Benefit Paid $ Burial Expense $ Amount of Burial Expense Paid by Respondents $ $ $ Witness, Honorable Court in County, day of , 20 , one of the Justices of the The applicant is the surviving spouse of the deceased and was living with the deceased at the time of injury and death. Location of Marriage Date of Marriage (Attorney must sign above and type name below) Applicant was previously married: Yes No Applicant had children from previous marriage: Yes No Respondents are relying upon the applicant's statement confirming his or her relationship to the deceased and children of Attorney(s) for the deceased. Note: If applicant is a widow, she must use her first or given name when signing the stipulation. Applicant Signature Date Office and P.O. Address Signed Witness: Telephone No.: Facsimile No.: Insurance Company Representative or E-Mail Address: Self-Insured Employer Signature Mobile Tel. No.: WKC-135 (R. 07/2001) American LegalNet, Inc. www.USCourtForms.com