COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.Better Workers CompensationWAIVER OF WORKERS COMPENSATION BENEFITSBuilt with you in mind.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)FOR RECREATIONAL OR FITNESS ACTIVITIESINSTRUCTIONS: This form should be completed to waive workers compensation coverage for voluntary participation in employer--sponsored recreational activities orfitness programs. In the space provided, list all employer-sponsored recreational activities and fitness programs for which the employee wishes to waive workerscompensation coverage. Line through any blank spaces. The employee must sign and date this form to acknowledge agreement. The employer shall retain the original for its files and provide a copy to the employee. The employer should submit a copy to BWC only when a claim is filed for an injury or occupational disease sustained in the employer-sponsoredrecreational activity or fitness program. For further information call 1-800-OHIOBWC (1-800-644-6292).. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Employee name (please print or type)DateTHE PEOPLE OF THE STATE OF NEW YORK TORisk numberEmployer namePursuant to Section 4123.01(C)(3) of the Revised Code, the employer and employee shall list thoseemployer-sponsored recreational activities and fitness programs for which the employee wishes to waive all rights to compensation and benefits under Chapter 4123 of the Revised Code. The waiver must be signed and dated prior to the date of injury or, in an occupational disease claim, the date of disability. Should an employee sustain an injury or occupational disease in an employer-sponsored recreational activity or fitness program which is not listed, the employee may be eligible for workers compensation benefits..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 roomRecreational activities/Fitness programsYour 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)The undersigned declares that he or she is a voluntary participant in the employer-sponsored recreationalAttorney(s) foractivities or fitness programs listed above. He or she hereby waives and relinquishes all rights to workers compensation benefits under Chapter 4123 of the Revised Code for any injury or disability incurred while participating in the above activities or programs. This waiver is valid for two calendar years. The waiver may not bar any workers compensation claim filed for death benefits by the employees dependents.Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Date signedEmployee signatureMobile Tel. No.:BWC-1286 (12/29/1997) C-159 (previously OIC-0161)American LegalNet, Inc. www.USCourtForms.com
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