COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. STATE OF NEW YORK : Index No. WORKERS' COMPENSATION BOARD DISABILITY BENEFITS BUREAU : 100 BROADWAY - MENANDS ALBANY, NY 12241-0005 Calendar THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT No. DISCRIMINATION. : JUDICIAL CLASS OF EMPLOYER'S APPLICATION FOR VOLUNTARY COVERAGE FORSUBPOENA Plaintiff(s) EMPLOYEES FOR WHOM DISABILITY BENEFITS ARE NOT REQUIRED BY LAW -against: (Employee Contribution NOT 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. Federal Employer's Identification Number (if Sole Proprietor, give Social Security Number).................................................... THE PEOPLE OF THE STATE OF NEW YORK U. I. Employer Registration Number.......................................... Total Number of employees................................................. TO Number of employees in class or classes for whom Disability Benefits are not required by law................................................ A. The EMPLOYER represents that he/she is of the New York State Disability Benefits Law. is not a covered employer within the definition thereof in Section 202 GREETINGS: B. The EMPLOYER hereby gives notice of his/her election, under Section 212 of Law, to provide benefits to the extent and in the manner WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before described below. , the Honorable at the Court All employees engaged in at professional capacity. located a County of All ,employees engaged in a teaching 20 in room on the day of , capacity. , at o'clock in the noon, and at any recessed 1.EMPLOYEES Executive Officer(s) evidence as a witness in this action on the part of the or adjourned date, to testify and give COVERED All employees in New York State employment for whom Disability Benefits are not required by law. Class or classes of employees at the place or places of employment as follows: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 2. BENEFITS As behalf this a Plan to was issued for a maximum the party on whoseprovided by subpoenabe filed under Section 211. penalty of $50 and all damages sustained as a TOresult of your failure to comply. Section 204, if there is no Plan for such employees. BE As provided under PROVIDED 3. METHOD OF Witness, Honorable Insurance. Certificate to be filed as required. PROVIDING Self-Insurance, subject toof Court in County, day approval of the 20 , Chair. BENEFITS , one of the Justices of the C. The EMPLOYER agrees that: (Attorney must sign above 1. No contributions to the cost of providing benefits shall be required from employees. and type name below) 2. 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-3. 3. At least (90) ninety days prior written notice that the Employer wishes to discontinue coverage will be given to the Attorney(s) for 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. Office and P.O. Address I hereby affirm, under the penalties of perjury, that I am__________________________________________of the above named EMPLOYER; that I have carefully read the foregoing application, including attachments, and that the facts therein stated are true. Telephone No.: Date Signed............................................. ........................................................................................ Facsimile No.: Tel. Number.............................................. E-Mail Address: Title.................................................................................. Mobile Tel. No.: DB-135 (8-03) Signature of Owner, Partner or Authorized Official American LegalNet, Inc. www.USCourtForms.com