COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : ENDORSEMENT : Index No. NO. _____________ Calendar No. INSURED _____________________________________________________________________________ Plaintiff(s) POLICY NO. ____________________EFFECTIVE DATE OF ENDORSEMENT -against__________ : JUDICIAL SUBPOENA : : NEW HAMPSHIRE AMENDATORY ENDORSEMENT : This policy is changed to provide: Defendant(s) : ...................................................... No. 1 This policy insures payment of Workers’ Compensation, within the financial limits THE PEOPLE OFby its STATE OF NEW YORK Revised Statutes established THE provisions, pursuant to TO Annotated, Chapter 281, as amended. No. 2 In the event the Insured has failed to fulfill all his obligations under the Workers’ GREETINGS: Compensation Law, the Insurer shall, at the directions of the Commissioner of Labor, deposit COMMAND YOU, that all businessInsured under the provisionsyouthis policy in attend before WE any money to be received by the and excuses being laid aside, of and each of you such bank , the Honorable as said Commissioner may determine, such money to be held in trust for the at the Court payment of any liabilities incurred by the Insured pursuant to Chapter 281, as amended. located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the No. 3 Any money to be paid to the Insured by the Insurer under the provisions of this policy or anyYour failure to comply with this subpoenaof Labor to be deposited inof court andbe held in you liable to money directed by the Commissioner is punishable as a contempt a bank to will make trust shall not be assignable, attachable or be liable in any penalty the debt of the Insured the party on whose behalf this subpoena was issued for a maximumway for of $50 and all damages sustained as a result unless incurred under Chapter 281 of the Workers’ Compensation Law, except in the of your failure to comply. event of the Insured’s bankruptcy and the U.S. Bankruptcy court assumes jurisdiction over this policy. Witness, Honorable , one of the Justices of the Court in County, day of , 20 No. 4 If either party to this policy desires to cancel said policy, such cancellation shall become (Attorney must sign above and type name below) effective for a period of 45 days (30 days if cancellation is for non-payment of premium) from date of filing of notice with the Department of Labor, State of New Hampshire, 95 Pleasant Street, State Office Park South, Concord, New Hampshire 03301. Attorney(s) for All other terms or conditions of this policy are not changed. If this endorsement is issued after the policy effective date, it must be signed by an Officer of the Insurer and countersigned by a Licensed Countersignature Agent of the Insurer in those State which Office and P.O. Address require countersignature. Signed at _______________________day of _________________________, 20_______ Telephone No.: __________________________________________ Facsimile No.: SI-EP-NH (4-96) E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com