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Non Compliance Notice Form. This is a Nevada form and can be use in Workers Comp.
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Tags: Non Compliance Notice, D-47, Nevada Workers Comp,
COUNTY . .
. . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
:
KENNY GUINN
Governor
STATE OF NEVADA
:
SYDNEY H. WICKLIFFE, CPA
Director
Plaintiff(s)
-against-
:
Index No.
Calendar No.
ROGER BREMNER
Administrator
CHARLES J. VERRE
Chief Administrative
JUDICIAL SUBPOENA Officer
:
http:/dirweb.state.nv.us/
:
DEPARTMENT OF BUSINESS AND INDUSTRY
DIVISION OF INDUSTRIAL RELATIONS
:
Workers’ Compensation Section
400 West King Street, Suite 400
1301 N. Green Valley Parkway, Suite 200
Defendant(s)
:
. . . . . . . . . . . . . . . . . . Carson .City, . . . . . . .89703. . . . . . . . . . . . . .Las .Vegas, Nevada 89074
. . . . . . . . Nevada . . .
..
(775) 684-7270 Fax (775) 687-6305
(702) 486-9080 Fax (702) 990-0364
Non-Compliance Notice
THE PEOPLE OF THE STATE OF NEW YORK
TO
Policy #:
Effective Date:
GREETINGS:
Expiration Date: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
at the
Court
located at
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
Policyholder Telephone #:
Fax::
or adjourned date, to testify and give evidence as a witness in this action on the part of the
the Honorable
Policyholder Contact Name:
County of
Policyholder Name & Mailing Address:
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.
Witness, Honorable
Court in
County,
Risk Class
Description
, one of the Justices of the
day of
20
Schedule of, Premium
Estimated Payroll
Rate
Premium
(Attorney must sign above and type name below)
Attorney(s) for
Check one:
Reopen:
New Business
Non-Compliance Dates:
Total Number of Employees:
Office and P.O. Address
Total Manual Premium:
Experience Modifier:
Telephone No.:
Total Estimated Annual Premium:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com
D-47 (Rev. 02/04)
