COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : South Dakota Department of Labor -againstDivision of Labor and Management : Plaintiff(s) Calendar No. JUDICIAL SUBPOENA CASE MANAGEMENT CERTIFICATION : COMPLIANCE : Claim Administrator Information: : Defendant(s) Claim Administrator Federal ID No ___________________ Carrier: Code__________ ...................................................... Name (DBA) _____________________________________________ Address ___________________________________ City __________________ State _______ Zip ____________ THE PEOPLE OF THE STATE OF NEW YORK Telephone Number ____________________ Form Completed By _______________________________________ TO Case Management Provider Information: GREETINGS: We certify, as an insurer, we have engaged the services of the following certified case management plan provider: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court Case Management Provider Federal ID No. ________________________________ located at County of Case Management Provider Name (DBA) ____________________________________________________________ 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 Case Management Provider Mailing Address Line 1 ___________________________________________________ Case Management Provider Mailing Address Line 2 ___________________________________________________ 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 ________________________________ State ________ Zip _________________ a Case Management Provider City subpoena was issued for a maximum penalty of $50 and all damages sustained as result of your failure to comply. Case Management Provider Telephone No. __________________________________ Witness, Honorable , one of the Justices of the and further certify that allCounty, compensation insurance policies issued or renewed by the insurer provide workers’ Court in day of , 20 case management services to its insured. This certification shall be filed with the South Dakota Department of Labor by March 31 of each year to demonstrate compliance with SDCL 58-20-24 or SDCL 62-5-21. (Attorney must sign above and type name below) Submitted by _____________________________________________ Date________________________ (Representative of the Insurer) DOL-LM-MC1 Revised 06/06/2003 Attorney(s) for Office and Submit form to: South Dakota Department of Labor Division of Labor and Management 700 Governors Drive P.O. Address Pierre, SD 57501-2291 Telephone (605)773-3681 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com