COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 NOTICE OF CHANGE OF WORKERS' COMPENSATION DISABILITY Plaintiff(s) STATUS : Calendar No. Date of Injury: MM DD : PA BWC Claim Number: JUDICIAL -against- YYYY SUBPOENA (IF KNOWN) : Employee First Name Index No. Social Security Number: Employer Last Name : Name Street 1 Street 1 Street 2 Street 2 : Defendant(s) : Zip . . . . . . . . . . . . . . . . . . . . . . . . .State . . . . . Code. . . . . . . . . . . . . . . .City/Town. . .. .... City/Town Telephone County State Zip Code County Telephone FEIN THE PEOPLE OF THE STATE OF NEW YORK Insurer or Third Party Administrator (if self-insured) TO Name Street 1 GREETINGS: Street 2 City/Town State Zip Code WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before 764 1297-1 Bureau Code , the Honorable at the Telephone Court located at County of County in room , on the day of , 20 , at o'clock in the noon, and at any recessed DATE OF THIS NOTICE: FEIN Claim Number or adjourned date, to testify and give evidence as a witness in this action on the part of the MM DD YYYY Attorney for Employee (if known) Attorney for Insurer/Employer (if known) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Name 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. Firm Name Firm Name Name Street 1 Street 2 Street 1 Witness, Honorable Court in County, City/Town State , one of the Justices of the day of Street 2 , 20 City/Town PA Attorney ID Number Telephone Zip Code State Telephone Zip Code PA Attorney ID Number (Attorney must sign above and type name below) Claim Representative First Name Attorney(s) for SEE IMPORTANT INFORMATION ON REVERSE. Last Name Telephone Office and P.O. Address This notice should be clearly completed (preferably typed) and original mailed to the Bureau at the address in the upper left corner. A copy must be sent to the employee and the employee's counsel (if known). Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: (OVER) LIBC-764 12-97 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. LIBC-764 : Calendar No. As a result of an impairment rating evaluation (examination), your disability status has changed. : Plaintiff(s) JUDICIAL SUBPOENA A change in disability status does not affect the amount of money you receive in your workers' compensation check. -againstPartial disability status does, however, have a maximum period of 500 weeks of benefits. : The specifics of this change are listed as follows: : Claimant Name: : Social Security Number: Defendant(s) : ...................................................... Date of Injury: MM DD YYYY Date you reached a total of 104 weeks of total disability: MM DD YYYY THE PEOPLE OF THE STATE OF NEW YORK Date initially established for the examination: MM DD YYYY TO Actual Date of the Rating Examination: MM DD YYYY Impairment Examining Physician: GREETINGS: Impairment Rating Percentage: % WE COMMAND YOU, that all business and excuses being laid aside, you and each Compensation This rating evaluation was conducted in accordance with Section 306(a.2) of the Pennsylvania Workers'of you attend before , the Honorable at the Court Act. County of located at ¨ The room referenced on the in above , Impairment Rating percentage has been ,used by your Insurance Carrier/Employer at any recessed day of , 20 at o'clock in the noon, and to change youradjournedcompensation statusgive evidence as a witness in disability status. part of the or workers' date, to testify and from total disability to partial this action on the The effective date of this status change is . (This effective date will be recorded on your claim MM DD YYYY record 60 days following the date of this notice) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to — for a the party on whose behalf this subpoena was issued OR —maximum penalty of $50 and all damages sustained as a result of ¨ The result your failure to comply. is that no change is occurring in your disability status. of this rating evaluation You may appealWitness, Honorable workers' compensation status to a Workers' Compensation Judge of Petition for an adjustment in your , one of the Justices the Review by filing a with the Bureau of Workers' Compensation, , 20 S. Cameron Street, Room 103, Harrisburg, 1171 Court in County, day of PA 17104-2501, which must include a qualified impairment rating physician's determination of impairment which is equal to or greater than 50%. If you have a question regarding this notice, please call or write the representative below. (Attorney must sign above and type Insurer/Employer Representative name below) First Name Last Name Signature Attorney(s) for Street 1 Street 2 City/Town Office and P.O. Address Telephone State Zip Code Bureau Code Telephone No.: Any individual filing misleading or incomplete information knowingly andFacsimile No.: with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may also beE-Mail Address: and civil penalties through subject to criminal Pennsylvania Act 165 of 1994. Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com