COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. IN THE CHANCERY COURT FOR HAMILTON COUNTY, TENNESSEE : CLAIM N0.___________ Calendar No. PROOF OF CLAIM (POC Form 1) ALL CLAIMS MUST BE FILED NOT LATER THAN 4:00 PM (EASTERN TIME) ON APRIL 19, 2002. : JUDICIAL SUBPOENA Plaintiff(s) FILE AT: CLERK & MASTER, HAMILTON COUNTY COURTHOUSE, STE 300, 201 E. 7TH ST., CHATTANOOGA, TN 37402 PART 1. EMPLOYEE. -against: N0. 02-0079 PART 1 1.1 Name___________________________________________________________________________ 1.2 DOB ___________________ 1.3 Street Address__________________________________________________________________ 1.4 Apartment #________________ 1.5 City_____________________________________________________ 1.6 State___________________ 1.7 Zip ___________________ : 1.8 Daytime Tel. (_____)_________________ 1.9 After hours Tel. (_____)________________ 1.10 Other Tel. (_____)_______________ : Defendant(s) : . . . . . . . . . . . you . . . . . . . . . . . . . . . . . . . . . .. .. PART 2. .ATTORNEY.. .Do . . . .have .an .attorney. representing .you? . . .NO . . . .YES If YES, complete PART 2. 2.1 Name_____________________________________________________________________________ 2.2 BPR #________________ 2.3 Law Firm _________________________________________________________________________________________________ 2.4 Address______________________________________________ 2.5 City___________________ 2.6 State_______ 2.7 Zip__________ 2.8 Tel (______)_________________Ext._______ 2.9 Fax (______)____________________2.10 Other (______)____________________ TO 2.11 E-mail ___________________________________________________________________________________________________ THE PEOPLE OF THE STATE OF NEW YORK PART 3. INJURY. You must complete PART 3. for each separate date of injury. Attach POC Form 2 as necessary. 3.1 Injury date____________________3.2 Employer when Injured________________________________________________________ GREETINGS: 3.3 Nature of injury (carpal tunnel, broken arm, etc.) _________________________________________________________________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before NO YES 3.5 Date Reported _______________ 3.6 To Whom ____________________________ , the Honorable at the Court located at 3.7 DateCounty of first worked for employer_____________________________ 3.8 Date last worked for employer_________________________ in room , on the day of , 20 , at o'clock in the noon, and at any recessed 3.9 Hourly wage at time of injury_______________________________ 3.10 COMP Rate at time of injury________________________ or adjourned date, to testify and give evidence as a witness in this action on the part of the 3.4 Injury reported to employer? 3.11 Have you received any benefits to date. NO YES 3.11 If YES, describe__________________________________________ ____________________________________________________________________________________________________________ 3.12 ( Benefits requested: failure to comply with this subpoena is punishableCurrent Medical of courtFuture Medical Care liable to Temporary Disability Permanent Disability Your as a contempt Care and will make you the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Other ______________________________________ Attach POC Form 3 for each benefit requested. result of your failure to comply. all that apply) PART 4. DOCTOR. You must complete PART 4. for each treating Doctor of each injury. Attach POC Form 2 as necessary. 4.1 Witness, Honorable , one of the Justices of the Name _____________________________________________________________ 4.2 City _________________________________ 4.3 Court in Restrictions? 4.5 Have you been released by the treating Doctor: 4.7 (Attorney Has Doctor said you have reached Maximum Medical Improvement (MMI)? NO must sign4.8 Date Reached __________________ YES above and type name below) 4.9 Has Doctor given you a Permanent Medical Impairment (PMI)? 4.11 NO County, day of , 20 YES 4.4 Describe______________________________________________________________________ NO YES 4.6 Date Released _______________________________________ NO YES 4.10 What percent (%)_________________________ To what part of your body ___________________________________________________________________________________ Attorney(s) for PART 5. LAWSUITS. You must complete PART 5. for each legal action regarding each claim. Attach POC Form 2 as necessary. 5.1 Court where action was filed _____________________________________ 5.3 Date action was filed _________________________ 5.4 Status (i.e., dismissed, pending, judgment entered, on appeal, etc.) _______ 5.2 Docket Number of Action _____________________ Office and P.O. Address ___________________________________________________________________________________________________________ By presenting to this PROOF OF CLAIM AGAINST BONDS, along with all attachments, to this Court, I am certifying that to the best of my knowledge, information, and belief, formed after an inquiry reasonable under the circumstances, that this claim is not being presented for any improper purpose subject to sanctions under Rule 11, Tennessee Rules of Civil Procedure. IF EMPLOYEE IS REPRESENTED BY AN ATTORNEY, BOTH MUST SIGN THIS PROOF OF CLAIM. Telephone No.: ________________________ ________________________________________________ Date [POC FORM 1, Rev. 2002.02.14] Employee Facsimile No.: E-Mail Address: ________________________________________________ Attorney for Employee Tel. No.: Mobile American LegalNet, Inc. www.USCourtForms.com