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Application For Reimbursement Form. This is a New Hampshire form and can be use in Second Injury Fund Workers Comp.
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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.:
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