COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS : Index No. DIVISION OF WORKERS’ COMPENSATION : APPLICATION FOR TORT VICTIMS’ COMPENSATION Calendar No. ORIGINAL AMENDED : JUDICIAL SUBPOENA Plaintiff(s) INSTRUCTIONS: 1. Type or Print clearly in ink. -against: 2. Last page of this form must be signed by claimant and notarized. 3. If claimant is incapacitated or disabled or a minor person, application MUST be : made by a parent, guardian or conservator or person’s spouse. 4. If a question is NOT APPLICABLE answer with N/A. : 5. Claim to be filed in person or by mail. MAILING ADDRESS TORT . . . . . . . COMPENSATION.PROGRAM . VICTIMS’ . . . . . . . . . . . . . . . . . . P.O. BOX 58, JEFFERSON CITY, MO 65102-0058 Claimant Name (Last, First, Middle) TELEPHONE NUMBER Defendant(s) : . . . . . . . . . . . . . . . . . .(573). 751-4231. .. ..... RELAY MISSOURI 1-800-735-2966 (TDD) 1-800-735-2466 (VOICE) Social Security Number Relationship to Victim Current Street Address City THE PEOPLE OF THE STATE OF NEW YORK Home Telephone Number State Work Telephone Number TO Birthdate Is Victim deceased? Age No Victim’s Address GREETINGS: Yes Zip Code Was Victim living with you at the time of injury or death? Yes Victim’s Name (Last, First, Middle) For Office Use Only Claim No. Social Security Number Dependents of Victim (Name, Address, Date of Birth) (Use additional sheet if necessary.) No Sex Male Female WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Date Tort Committed , the Honorable Nature of Tort Committed at the Court located at County of Briefly describe the injury(ies) sustained by the victim 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 Is the victim or the claimant currently incarcerated Was the victim on house arrest and confined in any for a crime unrelated to this application for federal, state, regional, county or municipal jail, prison or compensation? other correctional facility at the time of injury? Has the victim pled guilty or been found guilty of 2 or more felonies either involving a controlled substance or an act of violence within the past ten years? Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Yes No Yes No Yes No the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Brief description of the felonies result of your failure to comply. Witness, Honorable State or Local Agency, including a prosecuting attorney or law enforcement agency where the crime was reported Court in Date of Incident County, day of , one of the Justices of the , 20 Defendant’s Name (Attorney must sign above and type Number Telephone name below) Victim’s Employer’s Name Address City Is the victim a party in personal injury or wrongful death lawsuit? Yes No Name and address of the court where the judgment was entered State Zip Code Attorney(s) for Has the victim obtained a final monetary judgment in the lawsuit? Yes No (If the answer is “No” and the claimant is requesting a waiver, please complete attached statements.) Is the final monetary judgment being appealed? Yes No Name and address of the court where the appeal is pending Office and P.O. Address List all other sources for claimant or dependent to receive any benefit, payment of award as a result of the injury or death Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: WCT-1 (08-04) AI American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. Names and address of all hospitals, physicians or surgeons who treated or examined the victim for the injury or resulting death at the case may be. : Index No. (Use additional sheets if necessary.) : : Plaintiff(s) -against- Calendar No. JUDICIAL SUBPOENA : : Insurance information covering the liability of the tortfeasor: : Insurance Name Street Address. Policy Number Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .City . . . . . . . . . . . . . . . .. Name of Policy Holder Effective Date of Policy/Coverage State Zip Code Policy Limits if known It is not necessary to retainOF THE STATE OF NEW may have an attorney represent you in this claim. THE PEOPLE any attorney; however, you YORK Attorney Name Address Telephone Number TO City State Zip Code AUTHORIZATION FOR RELEASE OF INFORMATION TO CONDUCT AN INVESTIGATION, AND ASSIGNMENT OF SUBROGATION RIGHTS GREETINGS: I give permission to any hospital, physician, funeral home, law enforcement agency, insurance company, employer welfare or social agency, or any federal, state or local government agency to release all records and information that will help the Missouri Tort Victim Compensation Unit to WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before process my claim for compensation, to allow copies of such records to be made and to answer any questions made by or on behalf of the Missouri the Honorable at the Court Tort Victims’ Compensation Unit. located at County of I understand in room receiving this, form, the Missouri Tort Victims’ Compensation Unit will investigate thein the the information provided as that after on the day of , 20 , at o'clock truth of noon, and at any recessed well as other matters regarding this claim; and I consent to such investigation. This authorization is valid for two years from the date given below. or adjourned date, to testify and give evidence as a witness in this action on the part of the I acknowledge and agree that the State of Missouri is subrogated, to the extent of any compensation awarded to me, to all the claimant’s rights to recover benefits or advantages for economic loss from a source which is, or if readily available to the victim or claimant would be, a collateral source, and I hereby assign such rights to the State of Missouri so that it may protect its subrogation rights, and agree to assist the state in pursuing its subrogation right. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable the party on if I retain any attorney to represent me issued for a maximum I also agree to notify the Division: 1) sustained I agree to notify the Divisionwhose behalf this subpoena wasin a lawsuit related to this tort.penalty of $50 and all damagesin the event I receive restitution payment from the tortfeasor’s agent, or 2) in the event I initiate any legal proceeding or negotiations to recover damages result of your failure to comply. related to the tort upon which this claim is based. to as a I certify that I have read and understand the statements above; and that the information I have given is true and correct to the best of of the Witness, Honorable , one of the Justices my knowledge and belief and that these benefits will be denied if any such statements are not true. Court in County, Signature of Claimant day of , 20 Date (Attorney legal guardian. If the victim is under 18 years of age, this application must be signed by the parent or must sign above and type name below) On this __________ day of _____________________ 20___, before me personally appeared ______________________________, to be known to be the person described in and who executed the foregoing Tort Victims’ Compensation Application and acknowledged that they executed the same as their free act and deed. And said applicant declares that the information provided is true and correct to the best of their knowledge. Attorney(s) for Subscribed and sworn to before me the day and year first above written. _____________________________________________________ My commission expires: (Notary Seal) Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: WCT-1-2 (08-04) AI American LegalNet, Inc. www.USCourtForms.com , COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. WHO CAN APPLY? : The following persons are eligible for compensation Index No. : Calendar No. a) an uncompensated tort victim; and b) : if the uncompensated tort victim is deceased as a direct result of the tort, the class of persons specified in Section 537.080 (1); and JUDICIAL SUBPOENA Plaintiff(s) c) any relative of the uncompensated tort victim who legally assumes the obligation for, or who incurred medical or burial expenses, as a -against: direct result of the tort. : WHAT REQUIREMENTS MUST BE MET? An uncompensated tort victim is a person who: : d) Is a party in a personal injury or wrongful death lawsuit; or is a tort victim whose claim against the tortfeasor has been settled for the Defendant(s) policy limits of insurance covering the liability of such tortfeasor and such policy limits are inadequate in light of the nature and extent of : . . . . . . . . . . . . . . . . . . . . . . . . . . death; damages due. to.the personal. injury or. wrongful . . . . . . . . . . . . . . . . . . . . . . . . e) Unless described in paragraph (a) of this subdivision: a. Is a party in a personal injury or wrongful death lawsuit; or is a tort victim whose claim against the tortfeasor has been settled for the policy limits of insurance covering NEW YORK THE PEOPLE OF THE STATE OFthe liability of such tortfeasor and such policy limits are inadequate in light of the nature and extent of damages due to the personal injury or wrongful death; b. Has exercised due diligence in enforcing the judgment; and TO c. Has not collected the full amount of the judgment; f) Is not a corporation, company, partnership or other incorporated or unincorporated commercial entity; g) IsGREETINGS: not any entity claiming a right of subrogation; h) Was not on house arrest and was not confined in any federal, state, regional, county or municipal jail, prison or other correctional facility at the time heWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before or she sustained injury from the tortfeasor; i) Has not pleaded guilty to or been found guilty of two or more felonies, where such two or more felonies occurred within ten years of the located such felonies involved a controlled substance or an act of violence; and County of occurrence of the tort in question, and where either ofat j) Is a resident of the state of Missouri or sustained personal injury or death by a tort which occurred in the state of Missouri. the Honorable at the Court 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 The “Initial Claims Periods” is the period beginning on August 28, 2001, and ending on December 31, 2002 The claim shall be filed with the Division of Workers’ Compensation not later than two years after the judgment upon which the claim is based becomes final and all appeals are final, except with respect to the initial claims period. If there is no judgment, the claim must be filed within Your Section 516.120, except in this resulting in is punishable claim must be filed court and will make cause five years as enumerated infailure to comply with cases subpoena death, where the as a contempt ofwithin three years after theyou liable to of actionthe party enumerated in Section 537.100; except was respect to the a maximum penalty of $50 and all damages sustained as a accrues as on whose behalf this subpoena with issued for initial claims period. result of your failure to comply. With respect to the initial claims period, a claim may be filed with the Division of Workers’ Compensation based upon a judgment that is not expired or based upon a claim not reduced to judgment pursuant to Section 537.678 (2) and which would not be barred by the applicable statute of limitation if the tortfeasor could be served with process or had not filed for bankruptcy. Witness, Honorable , one of the Justices of the If the uncompensated tort victim is found personally liable of a cross-complaint of tort, or found to be contributorily or comparatively Court in County, day on , 20 negligent, compensation shall be limited to the extent of the favorable net amount awarded by the judge or jury. (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.: WCT-1-3 (08-04) AI American LegalNet, Inc. www.USCourtForms.com ,