COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : C-21 Index No. TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT : Calendar No. Division of Workers' Compensation : Nashville, Plaintiff(s) Tennessee 37243-0661 JUDICIAL SUBPOENA -against- : MONTHLY REPORT OF NON-COMPENSABLE INJURIES OR DISEASES INSTRUCTIONS : It is a crime to knowingly provide false, incomplete or misleading information to any party to aworkers' : compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial Defendant(s) of insurance benefits. : ...................................................... This report should include all claims closed in the previous month that resulted in lost time of seven days or less and/or incurred medical expenses. The report should be filed with this division by the fifteenth day of the month, covering the previous month. This report must contain the total medical expenses paid when closing out the claim. THE PEOPLE OF THE STATE OF NEW YORK Fatality claims, claims involving more than eight days lost time, or claims resulting in permanent disability must be reported on Form C-20 First Report of Injury. TO INSURANCE CARRIER NAME ____________________________________________________ INSURANCE CARRIER ADDRESS _________________________________________________ REPORT FOR THE MONTH OF ______________________ IN THE YEAR ________________ GREETINGS: CLAIMS OFFICE FILING THIS REPORT ______________________________________________ WE COMMAND YOU,EMPLOYER NAME &and excusesNUMBER NATURE OF and each of MEDICAL before that all business FEDERAL ID being laid aside, you you attend DATE OF DAYS , the Honorable at the Court ACCIDENT INJURY LOST EXPENSE located at County of 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 EMPLOYEE NAME 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 subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. 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 1. 2. 3. 4. 5. NUMBER OF CASES WITHOUT LOSS TIME FROM WORK ____________ MEDICAL EXPENSE OF CASES WITHOUT LOSS TIME FROM WORK Address___________ $ Office and P.O. NUMBER OF CASES WITH ONE TO SEVEN DAYS LOST FROM WORK ____________ TOTAL NUMBER OF LOST WORK DAYS (CUMULATIVE OF #3) ____________ MEDICAL EXPENSE WITH ONE TO SEVEN DAYS LOST FROM WORK $ ___________ Telephone No.: Facsimile No.: TOTAL NUMBER OF CASES FROM LINES 1 Address: ____________ E-Mail AND 3 LB-0027 (rev. 8/99) TOTAL MEDICAL EXPENSE FROM LINES 2 AND 5 $ ___________ Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com