COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .STATE OF NEW YORK WORKERS' COMPENSATION BOARD DISABILITY BENEFITS BUREAU 100 BROADWAY -MENANDS ALBANY, NY 12241-0005:::::::Index No.THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.Calendar No.EMPLOYER'S APPLICATION FOR VOLUNTARY COVERAGE FOR CLASS OF EMPLOYEES FOR WHOM DISABILITY BENEFITS ARE NOT REQUIRED BY LAW (Employee Contribution NOT Required)JUDICIAL SUBPOENAPlaintiff(s)-against-TO THE CHAIR, WORKERS' COMPENSATION BOARD:...............................................................................................................................herein called the EMPLOYER)Name of Employer...............................................................................................................................Defendant(s)Name Under Which Business is Conducted. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................................................................................................................................ (......)....................................AddressTelephone No.Federal Employer's Identification Number (if Sole Proprietor, give Social Security Number)....................................................THE PEOPLE OF THE STATE OF NEW YORK TOU. 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:B. 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.WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,All 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: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 room1.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. BENEFITSAs provided by a Plan to be filed under Section 211. As provided under Section 204, if there is no Plan for such employees.TO BE PROVIDED3. METHOD OFInsurance. Certificate to be filed as required. Self-Insurance, subject to approval of the Chair., one of the Justices of thePROVIDINGCourt in Witness, Honorableday of, 20 County,BENEFITSC. The EMPLOYER agrees that:(Attorney must sign above and type name below)No contributions to the cost of providing benefits shall be required from employees. 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-3. At least (90) ninety days prior written notice that the Employer wishes to discontinue coverage will be given to the Chair 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.2.1.3.Attorney(s) forOffice and P.O. AddressI hereby affirm, under the penalties of perjury, that I amof the above named EMPLOYER; that I have carefully read the foregoing application, including attachments, and that the facts therein stated are true.Telephone No.: Facsimile No.: E-Mail Address:Date Signed.....................................................................................................................................Signature of Owner, Partner or Authorized OfficialTel. Number..............................................Title..................................................................................Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comDB-135 (8-03)
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