COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.Permanent Authorization Better Workers Compensation Built with you in mind.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Policy numberTO:Ohio Bureau of Workers' CompensationRisk Underwriting 22nd Floor Self-Insured Department 26th FloorDBA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Please mark a box and return to 30 West Spring St. Columbus, OH 43215-2256Address EntityTHE PEOPLE OF THE STATE OF NEW YORK TOFax ((614) 728-0456NOTE: For this to be a VALID letter, it must be stamped by Risk Underwriting or by the Self-Insured Department for self-insured employers.GREETINGS:This is to certify that effective(Date)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 of(Representative name and Rep I.D. number)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 roomincluding its agents or representatives identified to you by them, has been retained to represent us before the Bureau of Workers' Compensation and the Ohio Industrial Commission in matters pertaining to our participation in the Workers' Compensation Fund according to the type of representation checked below. Please check the type of representation desired. See description of representatives on side 2.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.Type of Authorized Representation Employer Risk/Claim Representative (ERC) Risk Management Representative (RISK) Claim Management Representative (CLM), one of the Justices of theCourt in Witness, Honorableday of, 20 County,This authorization supersedes all permanent authorizations on file for the type of representation indicated above.(Attorney must sign above and type name below)I understand and agree any letters, requests, and actions initiated by a superseded authority will be processed completely.Attorney(s) forI understand that this authorization, now being granted, is of a continuous nature from the effective date indicated herein. However, I possess the right to terminate this authorization at any time through written notification to the Risk Underwriting or Self-Insured Department as appropriate.Office and P.O. AddressE-mail address Telephone numberFax numberPrint name and titleEmployer signatureDateTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:BWC-0502 (Rev. 3/27/2003) AC-2American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.BWC Authorized Representative Service/RolesCalendar No.Group Risk/Claim Representative (GRC) -responsible for management of group rating plans; will be designated as the authorized representative of each employer in the group for both risk and claim related issues; will be designated as the employers authorized representative on each claim for all employers in the group and copied on risk and claim correspondence; will have full access to each employers risk information and information pertaining to the workers compensation claims filed against the employer,, and authority to access such information on the Dolphin web site (ohiobwc.com). NOTE: A Group Risk/Claim Representative (GRC) can be updated by only the Risk Technical-Group Rating Unit based on the designation made by the groups sponsor. The AC-2 cannot be used to select a GroupJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TORisk/ClaimRepresentative(GRC)authorization.Thisrepresentativetypeonlyappliestoprivateemployers and public employer taxing districts. The Group Risk/Claim Representative (GRC) will be considered the authorized representative inhandlingriskrelatedissuesforanemployer;willbeconsideredtheauthorizedrepresentative inhandlingclaimrelatedissuesforanemployerifnoClaimManagementRepresentative(CLM) has been designated. Employer Risk/Claim Representative (ERC) will be designated as the employers authorized representative for both risk and claim management related issues; will be designated as the employers authorized representative on each claim under the employers policy number and copied on risk and claim correspondence. An Employer Risk/Claim Representative (ERC) will have full access to the employers risk information and information pertaining to the workers compensation claims filed against the employer,, and authority to access that information through the Dolphin web site (ohiobwc.com). TheEmployerRisk/ClaimRepresentative(ERC)willbeconsideredtheauthorizedrepresentative inhandlingriskrelatedissuesforanemployerifnoGroupRisk/ClaimRepresentative(GRC)has been designated; will be considered the authorized representative in handling claim related issues for an employer if no Claim Management Representative (CLM) or Group Risk/Claim Representative (GRC) has been designated.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 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 roomYour 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.RiskManagementRepresentative(RISK)willbedesignatedastheemployersauthorizedrepresentative for risk related issues; represents an employer on risk related issues only; will be copied on risk correspondence. A Risk Management Representative (RISK) will have access to only the employers risk related information and authority to access that information through the Dolphin web site (ohiobwc.com). The Risk Management Representative (RISK) will be considered the a
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