COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. State of Nevada : Index No. DEPARTMENT OF BUSINESS & INDUSTRY : DIVISION OF INDUSTRIAL RELATIONS No. Calendar Workers’ Compensation Section : Plaintiff(s) This form must be completed IN FULL and SIGNED to be processed JUDICIAL SUBPOENA -against- INDEX OF CLAIMS SYSTEM : CLAIM REGISTRATION/UPDATE/REQUEST DOCUMENT : REGISTRATION UPDATE : REQUEST Defendant(s) : REQUESTOR .IS:. . . . . . .Association. of .Self-Insured. Employer. . . . . . Self-Insured Employer ...... .. ......... .. .......... ........ Private Insurer Third-Party Administrator Requestor Name THE PEOPLE OF THE STATE OF NEW YORK FEIN # Date Submitted: INJURED EMPLOYEE SSN: TO Injured Employee Name: Last First Middle Initial GREETINGS: Sex: Male Female Birthdate: Claim Type: Lost Time Medical Only WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court Claim Number: Injury or Occupational Disease Date: located at County of in Closed , on the day of , To: ,NRS 616C.235(1) in the ReOpened and at any recessed at o'clock Date noon, Date Claimroom Closure Pursuant20 or adjourned date, to testify and give evidence as a witness in this 616C.235(2) part of the action on the NRS Third-Party Administrator: FEIN #: Self-Insured Employer: to comply with this subpoena is punishable as a contempt of FEINand will make you liable to Your failure court #: Assoc. of Self-Insured Employer: subpoena was issued for a maximum penalty of $50 and all damages sustained as a FEIN #: the party on whose behalf this FEIN # Privateresult of your failure to comply. Insurer: Private Insurer Address: Witness, Honorable Street Policy Effective Date: Court in County, day of Employer: Address: Street BODY PART CODE BODY PART DESCRIPTION City State Zip , one of the Justices of the Policy Expiration Date: , 20 FEIN # City State Zip (Attorney must sign above and type name below) Left, Right or Bilateral BODY PART BODY PART CODE DESCRIPTION Attorney(s) for Left, Right or Bilateral Office and P.O. Address Telephone No.: I hereby certify that the information contained on this form is true and correct. I also certify that I am a duly authorized Facsimile No.: representative of the requestor. E-Mail Address: Signature Date Mobile Tel. No.: D-38 (rev. 02/04) American LegalNet, Inc. www.USCourtForms.com