COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Settlement Application for Non-complying Employer ClaimsIndex No.Better Workers' CompensationCalendar No.Built with you in mind.Ohio Administrative Code 4123-14-05JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s) This form is to be used by the employer and/or employer's representative to request a decision by the Adjudicating Committee to settle the employer's non-compliance liability to the state insurance fund. This request must be signed by the employer and be notarized. Attach current financial information (a copy of the past three years, Federal and State income tax returns) to this application. Mail completed, signed and notarized form to: BWC, Legal Operations, Settlement Unit, P.O. Box 15398, Columbus, OH 43215-0398 OR fax to (614) 719-5941. Please call (614) 752-9040 with questions.Policy numberEmployer name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Employer Contact nameTelephone numberFax number()() E-mail addressStreet addressTHE PEOPLE OF THE STATE OF NEW YORK TOStateZIP codeCityClaim number(s)Injured worker nameStateZIP codeStreet addressCityGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable1. State reasons why a settlement would be in the best interest of both the applicant and the State of Ohio.,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 room2. Number of employees hired by applicant..................................................................................... 3. Location of employer business 4. Length of time employer has been in business ............................................................................ 5. Nature and type of employer business 6. Please explain why the employer did not have workers' compensation coverage when the injured worker was injured.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.7. Dollar amount employer proposes to pay for settlement................................................................ $, one of the Justices of theCourt in Witness, Honorableday of, 20 County,Note: Payment arrangements may be requested. 8. Is the employer presently carrying workers' compensation coverage? ..............................................No IfYesno, please state the reason why.(Attorney must sign above and type name below)9. Additional information you feel is relevant to your requestAttorney(s) forAttachments (please list):The information contained in said application is true to the best of my knowledge.Office and P.O. AddressSworn to before me and signed in my presence this day of , .Officer's signatureTelephone No.: Facsimile No.: E-Mail Address:TitleDateNotary Public, State ofMobile Tel. No.:BWC-3516 (4/19/2002) LEGAL-16American LegalNet, Inc. www.USCourtForms.com
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