AUTHORIZATION TO RECEIVEWORKERS' COMPENSATION CHECKBetter Workers' CompensationBuilt with you in mind.Attorney's name, address & I.D. numberInjured worker's name Claim numberCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::INSTRUCTIONS FOR COMPLETIONIndex No.This form must be completed in its entirety including the CORRECT CLAIM NUMBER. (In case of changeover, if new claim number is not known, list previous claim number.)Calendar No.The award must be specified. (In case of an application or motion that is pending for which the type of award is not known, number 15 may be checked.)Time limits for filing are as follows: 1) IC-92 or IC-92A (a) with IC-92 or IC-92A, (b) with Agreement of Permanent Partial Disability, (c) with Election, (d) at the hearingJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)or (e) with the Industrial Commission after hearing but prior to issuance of order. 2) District or Staff Hearing Officer -e.g. allowance -(a) prior to hearing, (b) at the hearing, or (c) within 14 days of the date ofmailing the findings at the office from which findings were mailed. 3) Regional Board of Industrial Commission Hearing -(a) prior to the hearing or (b) at the hearing. 4) BWC tentative order -(a) within 5 days of the date of mailing of the findings at the office from which findings were mailed or (b)with application generating order. 5) Any order from which there is no appeal or objection period -(a) at the hearing or (b) with application. 6) Informal hearings i.e. C-31-1, C-31RE, or COLA -in claim folder prior to preparation of payment order.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .An original must be filed for every claim for which an award is to be made. Altered authorizations will be honored if initialed by the party altering the form. Correcting a C-230 to reflect a "change over" claim number is not considered an alteration.I hereby authorize and direct BWC to mail directly to my attorney (to address above) the compensation check in the above numbered claim for the accrued portion of my award as specified -(Check only one block)THE PEOPLE OF THE STATE OF NEW YORK TO1. Temporary Total 2. Temporary Partial; impairment of earning capacity 3. Wage Loss 4. % Permanent Partial 5. Permanent Partial; scheduled losses6. V.S.S.R. 7. Death Award 8. Permanent Total 9. Lump Sum Settlement 0. Change of Occupation 1GREETINGS:11. Facial Disfigurement 12. Award based on D.H.O. hearing dated 13. Award based on S.H.O. hearing dated 14. Award based on Reg. Bd. hearing dated 15. Award based on I.C.O. hearing dated 16. Award ordered pursuant to Application or Motion signedWE 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 roomDateThis Authorization is with the limitation that my attorney does not have the authority to cash or endorse this check on my behalf.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.This Authorization shall be valid for a period of eighteen consecutive calendar months from the date of execution unless there are any subsequent hearings on the original issue (i.e., objection, appeal, reconsidera-tion) in which case the authorization is valid until a final decision is reached., one of the Justices of theDate Injured worker's signatureCourt in Witness, Honorableday of, 20 County,B.W.C. USE(Attorney must sign above and type name below)This Authorization is not honored by BWC because:It was not timely filed It was not properly completedReached the claim folder too late to honor Photocopy was submitted instead of originalAttorney(s) forOffice and P.O. AddressOfficeDate Claims representative's signatureBWC-1360 (Rev. 8/14/1997) C-230Telephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com
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