COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. STATE OF NEW YORK : Index No. WORKERS' COMPENSATION BOARD DISABILITY BENEFITS BUREAU : 100 BROADWAY - MENANDS Calendar No. ALBANY, NY 12241-0005 Plaintiff(s) : THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. JUDICIAL SUBPOENA EMPLOYER'S APPLICATION FOR VOLUNTARY COVERAGE FOR CLASS OF EMPLOYEES FOR -against- DISABILITY BENEFITS:ARE NOT REQUIRED BY LAW WHOM (Employee Contribution Required) : TO THE CHAIR, WORKERS' COMPENSATION BOARD: : ...........................................................................................................................................(herein called the EMPLOYER) Name of Employer Defendant(s) : ...................................................... ........................................................................................................................................................................................ Name Under Which Business is Conducted .......................................................................................................................................... (......).................................... Address Telephone No. THE PEOPLE OF THE STATE OF NEW YORK Federal Employer's Identification Number (if Sole Proprietor, give Social Security Number).................................................... TO U. I. Employer Registration Number.......................................... Total Number of employees................................................. Number of employees in class or classes for whom Disability Benefits are not required by law................................................ GREETINGS: is A. The EMPLOYER represents that he/she of the New York State Disability Benefits Law. is not a covered employer within the definition thereof in Section 202 WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before B. The EMPLOYER hereby gives notice of his/her election, at the Section 212 of Law, to provide benefits to the extent and under the Honorable Court in the manner described below. 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 All employees engaged in a professional capacity. All employees engaged in a teaching capacity. 1.EMPLOYEES Executive Officer(s). COVERED Your failure to comply New Yorksubpoena is punishable as a contempt Benefits and not required by liable to All employees in with this State employment for whom Disability of court are will make you law. Class or classes of employees issued place maximumof employment as follows: the party on whose behalf this subpoena was at the for a or places penalty of $50 and all damages sustained as a result of your failure to comply. 2. BENEFITS As provided by a Plan to be filed under Section 211. Witness, Honorable , one of the Justices of the TO BE As provided under Section 204, if there is no Plan for such employees. Court in County, day of , 20 PROVIDED 3. METHOD OF PROVIDING BENEFITS Insurance. Certificate to be filed as required. Self-Insurance, subject to approval of the Chair. (Attorney must sign above and type name below) C. The EMPLOYER agrees that: Attorney(s) for 1. Payment of benefits will be provided for a period of at least one year, and thereafter unless and until terminated as provided in item C-2. wishes to discontinue coverage will be given to the 2. At least (90) ninety days prior written notice that the Employer Office and P.O. Address Chair and to the covered employees; and provision will be made for the payment of obligations incurred on and prior to the effective termination date, including a rateable part of assessments for the current period, all subject to approval of the Chair. Telephone No.: Facsimile No.: E-Mail Address: PLEASE COMPLETE REQUIRED INFORMATION ON REVERSE Mobile Tel. No.: DB-136 (8-03) American LegalNet, Inc. www.USCourtForms.com , COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. D. The EMPLOYER hereby certifies that: : Calendar No. 1. More than one-half of employees for the class herein for whom benefits are to be provided have agreed to : contribute to the cost of providing the benefits. Plaintiff(s) JUDICIAL SUBPOENA -against: 2. The agreement of such employees was made in writing or by election held on........................................................ : 3. The contribution of each employee is at the rate of........................................... and the maximum contribution of any employee of $.......................... per................................. : Defendant(s) : The undersigned .hereby .affirms,. under the. penalties .of .perjury, that .he/she .is ..................................................................... ....... ..... ..... ....... ....... . ......... ..... of the above named EMPLOYER; that he/she has carefully read the foregoing application, including attachments, and that the facts therein stated are true. THE PEOPLE OF THE STATE OF NEW YORK TO Date Signed.............................................. .......................................................................................... Signature of Owner, Partner or Authorized Official Tel. Number.............................................. GREETINGS: Title................................................................................... WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the CERTIFICATE OF EMPLOYEE REPRESENTATIVE(S)the day of , 20 , at o'clock in noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the The undersigned authorized representative(s) of employees covered by this application hereby certifies (certify) that more than one-half of such employees have duly agreed to contribute to the cost of Benefits as described herein. 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. Date Signed............................................. .......................................................................................... Signature of Employee Representative Witness, Honorable Tel. Number............................................. day of Court in County, , one of the Justices of the Title.................................................................................... , 20 ....................................................................................... Name sign above and type name Union (Attorney mustof Association of Employee orbelow) Date Signed............................................. ......................................................................................... Signature of Employee Representative Attorney(s) for Tel. Number............................................. Title................................................................................... Office and P.O. Address ...................................................................................... Name of Association of Employee or Union Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. 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