Pennsylvania > Workers Comp
Petition For Physical Examination Or Expert Interview Of Employee (Section 314) LIBC-499 - Pennsylvania
| Petition For Physical Examination Or Expert Interview Of Employee (Section 314) Form. This is a Pennsylvania form and can be used in Workers Comp . |
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COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Index No. COMMONWEALTH OF PENNSYLVANIA PETITION FOR Social Security Number: DEPARTMENT OF LABOR AND INDUSTRY PHYSICAL EXAMINATION : Calendar No. BUREAU OF WORKERS' COMPENSATION OR EXPERT INTERVIEW Date of Injury: 1171 S. CAMERON STREET, ROOM 103 MM DD YYYY HARRISBURG, PA 17104-2501 OF EMPLOYEE : (TOLL FREE) 800-482-2383 PA BWCJUDICIAL SUBPOENA Claim Number: Plaintiff(s) (SECTION 314) (IF KNOWN) -againstEmployee First Name Street 1 Street 2 City/Town County Last Name Name Street 1 Street 2 State Zip Code : Employer : : Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . State. . . . Zip.Code. . . . . . . . . . . . . . . .City/Town .. . .. .... Telephone County Telephone FEIN THE PEOPLE OF THE STATE OF NEW YORK VS. TO Insurer or Third Party Administrator (if self-insured) Name Street 1 GREETINGS: Street 2 City/Town State Zip Code WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before 499 1297-1 Telephone Bureau Code , the Honorable at the Court located at County of County 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 inClaim Number on the part of the this action FEIN 1. the physical examination this subpoena was issued for a maximum penalty of $50 and all damages sustained as a party on whose behalf expert interview by result of your failure to comply. HEALTH CARE PROVIDER'S/EXPERT'S NAME AND ADDRESS AND FIELD OF SPECIALTY OR EXPERTISE The insurer/employer alleges that on subpoena is punishablerequested the employeeandsubmit to a you liable to , it as a contempt of court to will make Your failure to comply with thisMM DD YYYY , Witness, Honorable Court in County, 2. The date of last and the employee refused or failed to appear at such examination or interview. , one of the Justices of the expert interview of the . day of , 20 physical examination of the employee by a health provider or employee by the expert chosen by the insurer/employer was on 3. MM YYYY (Attorney DD sign above and type name below) must Wherefore, the employer petitions the Workers' Compensation Judge to order the employee to submit to a physical examination an expert interview by Attorney(s) for PROVIDER'S/EXPERT'S NAME HEALTH CARE or by such health care provider(s)/expert(s) as may be designated by the Workers' Compensation Judge at such time and place as may be set and determined. DATE OF THIS PETITION: MM DD YYYY Identify documents previously filed with the Bureau of Office and P.O. Address Workers' Compensation: NOTICE: Employer must indicate whether "physical examination" or "expert interview" is required by checking the appropriate boxes. Employee's answer must be filed with the Workers' Compensation Judge within twenty (20) days. (OVER) LIBC-499 REV 12-97 ¨ Notice of Compensation Payable ¨Telephone No.:Agreement Supplemental ¨Facsimile No.: Other E-Mail Address: ¨ Petition Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Plaintiff(s) -against: Index No. LIBC-499 Calendar No. JUDICIAL SUBPOENA CERTIFICATE OF SERVICE : I hereby certify that I have filed the Petition for Physical Examination or Expert Interview of Employee with the Bureau : of Workers' Compensation and have served by First Class Mail, a copy of same, on MM DD YYYY , on the following: : Defendant(s) : ...................................................... Claimant First Name Street 1 Street 2 Last Name Claimant's Attorney Name Firm Name Street 1 THE PEOPLE OF THE STATE OF NEW YORK TO City/Town State Zip Code Street 2 City/Town State Zip Code GREETINGS: DATE OF SERVICE: MM DD YYYY Telephone PA Attorney ID Number WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court 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 Petition filed by (Defendant's Attorney): Signature Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Name the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Firm Name result of your failure to comply. Street 1 Witness, Honorable Court in County, , one of the Justices of the day of , 20 Street 2 City/Town Telephone State Zip Code PA Attorney ID Number (Attorney must sign above and type name below) Attorney(s) CLAIMANT MUST BE SERVED for Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 Office and P.O. Address of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994. Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com
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