Third Party Election Form - Self-Insured Employer Third Party Action
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Third Party Election Form - Self-Insured Employer Third Party Action Form. This is a Washington form and can be use in Third Party - Subrogation Workers Comp.
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Tags: Third Party Election Form - Self-Insured Employer Third Party Action, F249-207-000, Washington Workers Comp, Third Party - Subrogation
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
Index No.
Calendar No.
Please be sure to include claim number on form.
Claimant’s name
Plaintiff(s)
:
JUDICIAL
Claim Number
-against-
:
Check here if address has changed, and enter new address below
:
Claimant’s mailing address
:
State
City
Defendant(s)
:
. .third. party. responsible.for. accident. (exclude. employer .or . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . co-employee)
Name of
Responsible party’s address
THIRD
PARTY
ELECTION
FORM
SUBPOENA
ZIP
Date of accident
City
Time of accident
State
AM
ZIP
THE PEOPLE OF THE STATE OF NEW YORK
Description and location of accident
TO
Witness to accident
Address
City
State
ZIP
Phone number
GREETINGS:
WE COMMAND YOU, thatAND COMPLETE OPTION A OR OPTION B of you attend before
PLEASE SELECT all business and excuses being laid aside, you and each
,
the Honorable
at the
Court
OPTION A. of
MY ATTORNEY OR at WILL PURSUE THIRD PARTY ACTION
located I
County
, the third
day of
, 20
at
o'clock in must
noon, and at any recessed
I wish in seek recovery fromon the party myself. I understand that if ,any recovery is made I the repay the Self Insured employer
to room
for myor adjourned date, to testify I also understand that I must notifyin this action onifthe part ofIthe a lawsuit. Finally, I
industrial insurance benefits. and give evidence as a witness the Self Insurer and when file
authorize the Self Insurer to communicate with my attorney.
SIGNATURE
X
Attorney’s name
Date:
Attorney’s address
this subpoena is punishable
Your failure to comply with
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
Attorney’s phone number
City
State
ZIP
result of your failure to comply.
Witness, Honorable
Court in
County,
OPTION B.
, one of the Justices of the
day of
, 20
I ASSIGN THE ACTION TO THE SELF INSURED EMPLOYER
I wish to assign any cause of action that I may have against a third party to the Self Insured sign above anddo not intend to pursue a
(Attorney must employer. I type name below)
third party action on my own and no recovery has yet been made. I authorize the release of information from my claim file so that a
third party action may be pursued. I understand that this assignment does not pertain to loss of consortium (love, affection and
companionship) claims of spouses, children or beneficiaries.
SIGNATURE
X
Attorney(s) for
Date:
Please complete entire form and mail to:
Office and P.O. Address
F249-207-000 self insured employer third party action 3-02
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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