Application For Reimbursement
Application For Reimbursement Form. This is a New Hampshire form and can be use in Second Injury Fund Workers Comp.
Tags: Application For Reimbursement, 9 WCA-2, New Hampshire Workers Comp, Second Injury Fund
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. STATE OF NEW HAMPSHIRE : DEPARTMENT OF LABOR 95 PLEASANT STREET CONCORD, NH 03301-3593 : Plaintiff(s) CHECK ONE BOX BELOW: -against- Calendar No. JUDICIAL SUBPOENA : APPLICATION FOR REIMBURSEMENT OF PAID ADJUSTED TOTAL DISABILITY BENEFITS : FROM SPECIAL FUND FOR ACTIVE CASES, RSA 281-A:29, 281-A:30 : APPLICATION FOR REIMBURSEMENT OF PAID COMBINED EARNINGS DIFFERENTIAL FROM SPECIAL FUND FOR SECOND INJURIES, RSA 281-A:15 III, 281-A:55 Defendant(s) : ......................................... ........... _______________________________________________ . ._________________________________________________ Employee Name Social Security Number _______________________________________________ _________________________________________________ Street THE PEOPLE OF THE STATE OF NEW YORK _______________________________________________ TO City, State and Zip Code Date of Injury _________________________________________________ Avg. Weekly Wage at Time of Injury (primary employment) _______________________________________________ Employer Name _________________________________________________ Avg. Weekly Wage at Time of Injury (concurrent employment, if applicable) _______________________________________________ GREETINGS: _________________________________________________ Street Original Compensation Rate (Primary Employment) WE COMMAND YOU, that all business _________________________________________________ _______________________________________________ and excuses being laid aside, you and each of you attend before City, State and Adjusted or Combined Earnings Compensation Rate , the Honorable Zip Code at the Court located at County of Effective date of RSA 281-A:29 Adjustment (if applicable): July 1, ______________ in room , on the day of , 20 , at o'clock in the noon, and at any recessed or Covered by this to testify and Request are: _________________________________________________________ Datesadjourned date, Reimbursementgive evidence as a witness in this action on the part of the Total Amount to be Reimbursed is $ ______________________. Application is made for reimbursement as set forth herein. Payments made through December 31 of the previous calendar Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to year should be included. Do not include payments made in the current calendar year. All requests for reimbursement shall the party on the Department of Labor no later than Septembermaximum penalty of $50 and all damages sustained as a whose behalf this subpoena was issued for a 1. be forwarded to result of your failure to comply. _________________________________________ Date Witness, Honorable Court in County, _______________________________________________________ Signature one , day of of the Justices of the , 20 _______________________________________________________ Insurance Carrier _________________________________________ _______________________________________________________ Adjusting Office Number Street (Attorney must sign above and type name below) _______________________________________________________ City, State and Zip Code FOR LABOR DEPARTMENT USE: Attorney(s) for Approved by: _________________________________________ Date: ________________________________________________ Paid: _________________________________________________ Office and P.O. Address Check No. _________________ Date: _____________ Comments: 9WCA-2 (9-94) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com