COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .STATE OF NEW YORK WORKERS' COMPENSATION BOARD DISABILITY BENEFITS BUREAU 100 BROADWAY -MENANDS ALBANY, NY 12241-0005:::::::THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s)EMPLOYER'S APPLICATION FOR VOLUNTARY COVERAGE FOR CLASS OF EMPLOYEESWHOM DISABILITY BENEFITS ARE NOT REQUIRED BY LAW (Employee Contribution Required)FOR-against-TO THE CHAIR, WORKERS' COMPENSATION BOARD:...............................................................................................................................herein called the EMPLOYER)Name of EmployerDefendant(s). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................................................................................................................................Name Under Which Business is Conducted............................................................................................................................... (......)....................................AddressTelephone No.THE PEOPLE OF THE STATE OF NEW YORK TOFederal Employer's Identification Number (if Sole Proprietor, give Social Security Number)....................................................U. I. Employer Registration Number.......................................... Total Number of employees.................................................Number of employees in class or classes for whom Disability Benefits are not required by law................................................A. The EMPLOYER represents that he/shea covered employer within the definition thereof in Section 202 of the New York State Disability Benefits Law.isis notGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableB. The EMPLOYER hereby gives notice of his/her election, under Section 212 of Law, to provide benefits to the extent and in the manner described below.,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomAll employees engaged in a professional capacity. All employees engaged in a teaching capacity. Executive Officer(s). All employees in New York State employment for whom Disability Benefits are not required by law. Class or classes of employees at the place or places of employment as follows:1.EMPLOYEESCOVEREDYour 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.2. BENEFITS, one of the Justices of theAs provided by a Plan to be filed under Section 211. As provided under Section 204, if there is no Plan for such employees.Court in Witness, Honorableday of, 20 County,TO BE PROVIDED3. METHOD OFInsurance. Certificate to be filed as required. Self-Insurance, subject to approval of the Chair.PROVIDING(Attorney must sign above and type name below)BENEFITSC. The EMPLOYER agrees that:Attorney(s) for1.Payment of benefits will be provided for a period of at least one year, and thereafter unless and until terminated as provided in item C-2.Officewishesand P.O. Address2.At least (90) ninety days prior written notice that the Employerto discontinue coverage will be given to theChair and to the covered employees; and provision will be made for the payment of obligations incurred on and prior to the effective termination date, including a rateable part of assessments for the current period, all subject to approval of the Chair.Telephone No.: Facsimile No.: E-Mail Address:PLEASE COMPLETE REQUIRED INFORMATION ON REVERSEMobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comDB-136 (8-03)COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.D. The EMPLOYER hereby certifies that:Calendar No.1.More than one-half of employees for the class herein for whom benefits are to be provided have agreed to contribute to the cost of providing the benefits.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)The agreement of such employees was made in writing or by election held on........................................................2.3.The contribution of each employee is at the rate of........................................... and the maximum contribution of any employee of $.......................... per.................................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .The undersigned hereby affirms, under the penalties of perjury, that he/she is ..................................................................... of the above named EMPLOYER; that he/she has carefully read the foregoing application, including attachments, and that the facts therein stated are true.THE PEOPLE OF THE STATE OF NEW YORK TODate Signed........................................................................................................................................Signature of Owner, Partner or Authorized OfficialTel. Number..............................................Title...................................................................................GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofCERTIFICATE OF EMPLOYEE REPRESENTATIVE(S)o'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomThe undersigned authorized representative(s) of employees covered by this application hereby certifies (certify) that more than one-half of such employees have duly agreed to contribute to the cost of Benefits as described herein.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.Date Signed................................................................................................
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