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 STOPPING TEMPORARY Plaintiff(s) COMPENSATION Social Security Number: : First Name Calendar No. Date of Injury: : MM DD PA BWC Claim Number: JUDICIAL YYYY SUBPOENA (IF KNOWN) -againstEmployee Index No. : Employer Last Name Name Street 1 Street 1 Street 2 : Street 2 City/Town : Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . State. . . . Zip.Code . . . . . . . . . . . . . . . .City/Town . . .. . .. .... County Telephone 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 WE COMMAND 1297-1 that all business and excuses being laid aside, you and each of you Code before YOU, attend 502 , the Honorable at the Telephone Court Bureau Code located at County of County 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 Claimthis action on the part of the in Number DATE OF THIS NOTICE: FEIN MM DD YYYY NOTICE TO EMPLOYEE: Your failure to comply with temporary compensation as a contempt of court This notice is being sent because payment of this subpoena is punishableis being stopped as of and will make you liable to . MM DD the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages YYYY sustained as a result of temporary compensation The paymentof your failure to comply. does not mean that your employer assumed responsibility for your injury. Your employer and you retain all rights, defenses and obligations with regard to the claim. Further, the payment of temporary compensation may not be used to support a claim for benefits in a future proceeding. Witness, Honorable , one of the Justices of the ¨ WE HAVE ACCEPTED RESPONSIBILITY FOR YOUR CLAIM, AND ATTACHED IS A Court in County, day of , 20 NOTICE OF COMPENSATION PAYABLE OR AN AGREEMENT FOR COMPENSATION; OR, ¨ WE HAVE DECIDED NOT TO ACCEPT LIABILITY, AND ATTACHED IS A NOTICE OF WORKERS' COMPENSATION DENIAL. IF YOU BELIEVE YOU SUFFERED A WORK-RELATED INJURY, YOU WILL BE REQUIRED TO and type CLAIM PETITION (Attorney must sign above FILE A name below) WITH THE BUREAU OF WORKERS' COMPENSATION IN ORDER TO PROTECT YOUR FUTURE RIGHTS. You have three (3) years from the date of injury or discovery of your condition to file a Claim Petition for benefits. Attorney(s) to Since time limits can vary depending on the facts of your situation, you may wishfor contact an attorney if you believe you may have a claim. Authorized Agent for Insurer or TPA (if self-insured) First Name Last Name Signature Telephone The original must be filed with the Bureau of Workers' Office This notice must Compensation.and P.O. Address be sent and filed no later than five (5) days after the last payment of temporary compensation. A copy of this notice is to be sent to the injured employee. Telephone No.: Facsimile No.: Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 E-Mail Address: of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Mobile Tel. No.: Pennsylvania Act 165 of 1994. LlBC-502 REV 12-97 American LegalNet, Inc. www.USCourtForms.com