COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : FORM 401 as of 05/0 1 Index No. STATE OF UTAH : LABOR COMMISSION Calendar No. DIVISION OF INDUSTRIAL ACCIDENTS P.O. BOX 146610, 160 E 300 SO, SALT LAKE CITY, UT 84114-6610 : JUDICIAL SUBPOENA (801)530-6800 (800)530-5090 (TTD)530-7685 FAX 530-6804 Plaintiff(s) -against: REQUEST FOR CLAIMS RESOLUTION CONFERENCE : EMPLOYEE INFORMATION : NAME: DATE OF INJURY: Defendant(s) : SS #:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PHONE #: . .... ADDRESS: STREET THE PEOPLE OF THE STATE OF ZIP YORK CITY, STATE, NEW NO HAVE YOU RETAINED AN ATTORNEY TO ASSIST YOU WITH YOUR CLAIM ? YES TO *THE LABOR COMMISSION NEITHER REQUIRES NOR DISCOURAGES LEGAL REPRESENTATION IN THE PURSUIT OF A WORKERS COMPENSATION CLAIM. EMPLOYER INFORMATION GREETINGS: NAME: PHONE laid WE COMMAND YOU, that all business and excuses being #: aside, you and each of you attend before , the Honorable at the Court ADDRESS: of located at County STREET 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 CITY, STATE, ZIP INSURANCE CARRIER INFORMATION Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to NAME: party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a PHONE #: the result ADDRESS: of your failure to comply. ADJUSTOR: STREET Witness, Honorable CITY, STATE, ZIP Court in County, day of (IF KNOWN) , one of the Justices of the , 20 ISSUES NEEDING RESOLUTION: 1. (Attorney must sign above and type name below) 2. 3. - If more room Is needed, please use the back of this form. Attorney(s) for I REQUEST TO HAVE A CLAIMS RESOLUTION CONFERENCE SCHEDULED TO RESOLVE THE ABOVE ISSUES. Phone #and Office REQUESTOR'S SIGNATURE: Requestor's relationship to claim: Employer Employee Other (Please specify): Adjustor P.O. Address Applicant's Counsel Date: Defense Counsel Telephone No.: Your Claims Resolution Conference will be scheduled within 14 days from the time the Division of Industrial Accidents receives agreement from both parties to participate In this process. Facsimile No.: CASE NUMBER E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com