COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Index No. : Calendar No. Gradual Return to Work : Agreement JUDICIAL SUBPOENA INSTRUCTIONS: • Please print or type Plaintiff(s) • Make sure to enter 4 digits for the year in all date fields. • Follow the distribution list at the bottom of the form. : -againstInjured worker name Claim number : Name of employer Job title : 1. The injured worker will be employed on a gradually increasing schedule (see grid below) in the position listed above. The Defendant(s) : injured. worker . will. have .all. the. . . . . . . privileges,. . . . .responsibilities .of all other similarly situated employees, with the . . . . . . . . . . . . . . . . . . rights, . . . . . . . and . . . . . . . . . . . exception of the following: The injured worker will begin gradual-return-to-work on__________________________________. 2. Employer Reimbursement Method: The employer agrees to pay the injured worker for the equivalent of full time work for the position, at the full gross wage of $__________ per hour or $_________ per week. BWC will reimburse the employer according to the grid below. OF THE STATE OF NEW YORK THE PEOPLE 3. Injured Worker Payment Method: The Employer agrees to pay the injured worker for actual hours worked a the full gross wage of $ __________ per hour or $_________ per week, and BWC pays the injured worker for hours not worked, not to exceed the TO injured worker’s regular LM rate. 4. Work hours will not be extended unless specifically agreed to by the employer, physician, injured worker, and BWC. 5. This agreement may be cancelled by either the employer or the BWC with ten (10) days written notice to each of the other parties, or upon the termination of the injured worker’s employment. GREETINGS: 6. Documentation of gross wages (i.e., signed payroll records as well as actual hours worked) paid to the injured worker for each pay period must be submitted to BWC for verification before reimbursement will be paid. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before at the Court NOTE: the Honorable used to reimburse the employer or to make payment to the injured worker. The weekly GRTW LM rate must not , This form may be Countythe injured worker’s previous locatedLM rate. exceed of weekly at in room , on the day of , 20 , at o'clock in the noon, and at any recessed Please indicate which testify is being evidence as a witness in this action Employer Injured worker or adjourned date, tomethod and giveused by checking the appropriate box: on the part of the reimbursement receipt of GRTW LM GRTW Schedule GRTW Your Dates failure From: From: From: Hours Total Hours Not Weeks Worked Worked subpoena is punishable Wages Reimbursement GRTW LM to be paid by to be paid by BWC to be paid by Employer to IW of courtEmployer makeBWC to IW to and will as a contempt you liable to comply with this to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a $ $ $ To: result of your failure to comply. $ From: To: From: To: From: day of To: , 20 $ $ $ $ $ $ To: Witness, Honorable Court in To: County, $ $ , one of the Justices of the (Attorney must sign above and type name below) $ $ $ $ $ $ Attorney(s) for Authorized employer name Address City Employer representative signature & title Injured worker signature State Office and P.O. Address 9-digit ZIP Code Date Date Telephone No.: Date Facsimile No.: E-Mail Address: Distribution - BWC claim file, Injured worker, Injured worker representative, Employer, Employer representative Mobile Tel. No.: MCO assigned vocational case manager signature BWC-2974 (Rev. 11/21/2001) RH-24 American LegalNet, Inc. www.USCourtForms.com