Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Application For Use Of Second Injury Fund Form. This is a New Hampshire form and can be use in Second Injury Fund Workers Comp.
Loading PDF...
Tags: Application For Use Of Second Injury Fund, WCSIF-1, New Hampshire Workers Comp, Second Injury Fund
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Plaintiff(s)
Calendar No.
:
EXHIBIT
JUDICIAL SUBPOENA 0
-againstAPPLICATION FOR THE USE OF THE:SECOND INJURY FUND
:
This application must be filed within one hundred weeks from the date of a
subsequent injury to a permanently impaired employee (RSA 281-A:54, V).
:
Defendant(s)
:
......................................................
______________________________________________
Employee Name
THE PEOPLE OF THE STATE OF NEW YORK
__________________________
Date of Subsequent Injury
TO
______________________________________________
Employer Name
__________________________
Date of Subsequent Disability
GREETINGS:
______________________________________________
__________________________
WE COMMAND YOU, that all business and excuses being laidAdjusting Office Number attend before
aside, you and each of you
Employer’s Insurance Carrier
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
I, the undersigned, __________________________________________________________
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Name
Company
give due notice of the above referenced possible claim against the Second Injury Fund. I
Your failure to comply with this subpoena is punishable as a Section of court and will make
hereby apply for the use of the fund under the provisions of contemptA:54 of RSA 281 and 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 Section failure to comply. New Hampshire Code of Administrative Rules. I acknowledge that
of your Lab 506.04 of the
Witness, Honorable
, one of without regard to
all reimbursable benefits payable under RSA 281 shall be paid direct andthe Justices of the
Court in
County,
day of
, 20
reimbursement. I further acknowledge that eligibility for reimbursement of such payments
from the Second Injury Fund shall be subject to the proper filing of medical evidencebelow) proof
(Attorney must sign above and type name and
of employer knowledge as detailed in Section Lab 506.04.
Attorney(s) for
_____________________
Date of Application
Form No. WCSIF-I (9/98)
_________________________________________________
Signature
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com
