COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.BWC Subrogation Referral FormCalendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)ClaimantClaim No.Date of InjuryClaimants PI Attorney and AddressThird Party Name and Address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TOTelephone No. Telephone No. Third Partys Insurance CompanyThird Partys Attorney (If known)GREETINGS:Address, Claim No. and Claims RepName and addressWE 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 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 roomDescription of AccidentYour 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., one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Refer to:Subrogation DepartmentReferred By: PO Box 15487Telephone: Attorney(s) forColumbus, OH 43215Affiliation: Phone: (614) 466-6600Date: Fax: (614) 728-7278Office and P.O. AddressAttached:MVA Report Other Specify Telephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com
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