California > Workers Comp > General
Statement Of Employer Payments PW-26 - California
| Statement Of Employer Payments Form. This is a California form and can be used in General Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Statement of Employer Payments No. Index Date: Prime: Subcontractor: PROJECT NAME: PROJECT CONTRACT NO.: : In Reply, Refer to Case No: Plaintiff(s) -againstCounty/location: HEALTH AND WELFARE Address, City and Zip Calendar No. : : : : : JUDICIAL SUBPOENA NAME OF PLAN ....... ADMINISTRATOR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . and. Zip. . . . . Address, City . . . . CLASSIFICATION(S) USED Defendant(s) CONTRIBUTION PER CLASSIFICATION PER HOUR THE PEOPLE OF THE STATE OF NEW YORK CONTRIBUTIONS: TO WEEKLY_____ MONTHLY_____ PENSION Address, City and Zip Address, City and Zip QUARTERLY_____ ANNUALLY_____ NAME OF PLAN ADMINISTRATOR GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before CONTRIBUTION PER CLASSIFICATION PER HOUR , at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed CONTRIBUTIONS: WEEKLY_____ MONTHLY_____ QUARTERLY_____ ANNUALLY_____ or adjourned date, to testify and give evidence as a witness in this action on the part of the CLASSIFICATION(S) USED the Honorable VACATION/HOLIDAY Address, City and Zip NAME OF PLAN 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 Address, City and Zip was issued for a maximum penalty of $50 and all damages sustained as a ADMINISTRATOR result of your failure to comply. CLASSIFICATION(S) USED CONTRIBUTION PER CLASSIFICATION PER HOUR Witness, Honorable Court in County, CONTRIBUTIONS: WEEKLY_____ , one of the Justices of the day of , 20 QUARTERLY_____ ANNUALLY_____ MONTHLY_____ TRAINING Address, City and Zip Address, City and Zip NAME OF PLAN ADMINISTRATOR CLASSIFICATION(S) USED (Attorney must sign above and type name below) Attorney(s) for CONTRIBUTION PER CLASSIFICATION PER HOUR Office and P.O. Address CONTRIBUTIONS: WEEKLY_____ MONTHLY_____ QUARTERLY_____ ANNUALLY_____ IF YOU USE OTHER PLANS NOT LISTED ABOVE, YOU MAY USE THE BACK OF THIS FORM TO PROVIDE THIS ADDITIONAL INFORMATION PW 26 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com
|
|||||||
