COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .State of New York WORKERS' COMPENSATION BOARD DISABILITY BENEFITS LAW:::::::Index No.Calendar No.EMPLOYER'S APPLICATION TO HAVE ASSOCIATION, UNION OR TRUSTEE PLAN ACCEPTED AS EMPLOYER'S PLANJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)An EMPLOYER participating in a Plan and Agreement of an association of employers or employees, union ortrustees shall file this application in duplicate if the Plan is insured or in triplicate if the Plan is self-insured.Name of Employer(HEREIN CALLED THE EMPLOYER). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Name Under Which Business is ConductedNumber and StreetCityStateZip CodePEOPLE OF THE STATE OF NEW YORKEmployer's U. I. Registration No. (If None, Give Reason)Federal Employer's Identification Number (If Sole Proprietor, Give Social Security No.)GREETINGS:A. The EMPLOYER requests acceptance of this PLAN and AGREEMENT identified by W.C.B. Plan NumberWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the Honorable,of as the EMPLOYER'S Plan.Association, Union or Trusteeslocated at of1. The Plan covers the EMPLOYER'S employees as follows:o'clock in the day ofnoon, and at any recessed , on the, 20, at adjourned date, to testify and give evidence as a witness in this action on the part of theAll employees eligible for benefits under the New York Disability Benefits Law. All employees eligible for benefits under the Disability Benefits Law except those classes of employees eligible to receive Benefits under anotherpolicy or plan accepted by the Chair. Only the following class or classes of employees:Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a your failure to comply.Witness, Honorable, one of the Justices of the2. Number of EMPLOYER'S employees covered under this Planday of, 20 County,3. The EMPLOYER became (will become) a Participating Employer in the Plan on(Date)B. The EMPLOYER agrees:(Attorney must sign above and type name below)1. That all eligible employees will be provided Benefits either by the Plan or in one or more of the ways specified in Sec. 211 of the Disability Benefits Law.2. That any excess of the aggregate contributions of employees over the cost of providing Benefits and any uncommitted balance of employeeAttorney(s) forcontributions remaining at the termination of this Plan shall be distributed or applied for the sole benefit of employees or otherwise be applied or disposed of pursuant to Sec. 210, subdivision 4, and Sec. 216 of the Disability Benefits Law.3. That the Plan Benefits will be continued until the Employer has filed written notice with the Chair of the termination of the Plan.Office and P.O. AddressEmployerDate SignedByTelephone No.: Facsimile No.: E-Mail Address:Signature of Owner, Partner or Authorized OfficerTelephone No.:TitleMobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comDB-802 (8-03)Continued on reverseCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::CERTIFICATION BY ASSOCIATION, UNION OR TRUSTEESIndex No.STATE OF NEW YORKCalendar No.COUNTY OF...........................................................................JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)..........................................................................................................................being duly sworn, deposes and says:That he or she is the.......................................................... of the...............................................................................Name of Association, Union or Trustees Name of Authorized Officialand is duly authorized to execute this affidavit of certification on behalf of said Association, Union or Trustees.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .That EMPLOYER became (will become) a participating Employer in the Plan on.................................................that, during the term of the Plan as accepted by the Chairman of the Workers' Compensation Board, the EMPLOYER'S participation will continue to be effective until ten days after a written notice of termination is served on the EMPLOYER and filed with the Chairman of the Workers' Compensation Board by or on behalf of the Association, Union or Trustees.PEOPLE OF THE STATE OF NEW YORKThat the employees specified on this form by the EMPLOYER will be provided benefits under the accepted Plan of this Association, Union or Trustees.GREETINGS:...............................................................................Signature of Authorized OfficialWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the Honorable,Sworn to before me thislocated at ofo'clock in the day ofnoon, and at any recessed , on the, 20, at adjourned date, to testify and give evidence as a witness in this action on the part of the........................day of.....................................................................................................................................Signature of Notary PublicYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a your failure to comply.Witness, Honorable, one of the Justices of theINSTRUCTIONSday of, 20 County,1. Each completed form is to be executed by the EMPLOYER, certified by the Association, Union or Trustees, and sworn to before a notary public before filing.(Attorney must sign above and type name below)2. Mail the form for filing, in duplicate, to:WORKERS' COMPENSATION BOARDAttorney(s) forDISABILITY BENEFITS BUREAUPLANS ACCEPTANCE UNIT 100 BROADWAY-MENANDS ALBANY, NY. 12241-0005Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.Mobile Tel. No.:DB-802 (8-03) ReverseAmerican LegalNet, Inc. www.USCourtForms.comwww.wcb.state.ny.us
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