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Proof Of Claim Addendum Form. This is a Tennessee form and can be use in Hamilton Local County.
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Tags: Proof Of Claim Addendum, POC 2, Tennessee Local County, Hamilton
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Calendar
PROOF OF CLAIM ADDENDUM (POC Form 2) No.
:
JUDICIAL SUBPOENA
EMPLOYEE NAME ____________________________________________________________________________________________
Plaintiff(s)
PART 3. ADDITIONAL INJURY. You must complete PART 3. for each separate date of injury. Attach :CLAIM ADDENDUM (POC Form 2) as necessary.
-against3.1
Injury date____________________3.2 Employer when Injured________________________________________________________
3.3
:
Nature of injury (carpal tunnel, broken arm, etc.) _________________________________________________________________
3.4
Injury reported to employer?
3.7
Date first worked for employer_____________________________ 3.8 Date last worked for employer_________________________
3.9
.. ... . ........................................ ....
Hourly .wage. at .time of injury_______________________________ 3.10 .COMP Rate at time of injury________________________
NO
YES
3.5
Date Reported _______________ 3.6 To Whom ____________________________
:
Defendant(s)
3.11
Have you received any benefits to date.
NO
:
YES 3.11 If YES, describe__________________________________________
____________________________________________________________________________________________________________
THE PEOPLE OF THE STATE OF NEW YORK
3.12
(
Benefits requested:
TO
all that apply)
Temporary Disability
Permanent Disability
Current Medical Care
Future Medical Care
Other _______________________________________________________________________________
PART 4. ADDITIONAL DOCTOR. You must complete PART 4. for each treating Doctor of each injury. Attach CLAIM ADDENDUM (POC Form 2) as necessary.
4.1
Name _____________________________________________________________ 4.2 City _________________________________
4.3
GREETINGS:
Restrictions?
NO
4.5
Have you been WE COMMAND YOU, that all business and 4.6 Date Released _______________________________________
released by the treating Doctor:
NO
YES excuses being laid aside, you and each of you attend before
YES
4.4
Describe______________________________________________________________________
Court
NO YES 4.8 Date Reached __________________ ,
located at
County of
4.9 Has Doctor given you a Permanent Medical Impairment (PMI)?
in room
, on the
day of
, 20 NO, at YES 4.10 What percent (%)_________________________
o'clock in the
noon, and at any recessed
or adjournedyour bodytestify and give evidence as a witness in this action on the part of the
date, to __________________________________________________________________________________
4.11 To what part of
4.7
the Honorable
at the
Has Doctor said you have reached Maximum Medical Improvement (MMI)?
PART 5. ADDITIONAL LAWSUITS. You must complete PART 5. for each legal action regarding each claim. Attach CLAIM ADDENDUM (POC Form 2) as necessary.
5.1
Court where action was filed _____________________________________
5.3
Your _________________________ 5.4 Status (i.e., dismissed, pending, judgment entered, will make you liable to
Date action was filed failure to comply with this subpoena is punishable as a contempt of court and on appeal, etc.) _______
5.2
Docket Number of Action _____________________
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.
Additional Comment (Refer to Part number) _______________________________________________________________________
Witness, Honorable
Court in
County,
, one of the Justices of the
_______________________________________________________________________________________________________________________________________
day of
, 20
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
(Attorney must sign above and type name below)
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Attorney(s) for
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Office and P.O. Address
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Telephone No.:
_______________________________________________________________________________________________________________________________________
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
_______________________________________________________________________________________________________________________________________
[POC Form 2, Rev. 2002.02.14]
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