Request For Prosthetic Repair Or Replacement From Second Injury Fund {51702}

COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ...... . INDIANA. WORKERS. COMPENSATION BOARD : Second Injury Fund 402 W Washington Street, Room W196 Indianapolis, Indiana 46204 (317) 232-3808 www.in.gov/wkcomp STATE USE ONLY Index No. Calendar No. : : State Form Application Number: Plaintiff(s) REQUEST FOR PROSTHETIC REPAIR ORJUDICIAL SUBPOENA REPLACEMENT -against- THE SECOND INJURY FUND : FROM Instructions: Please type or print . Sign form in shaded box. Send the completed application with attachments to the above address. Form must be filled out completely. : : Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . EMPLOYEE. INFORMATION .......... ........... Name of plaintiff/employee Date of Birth Street Address THE PEOPLE OF THE STATE OF NEW YORK TO State ZIP Code City Telephone Number Social Security Number* Signature GREETINGS: Date WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court PROSTHETIC INFORMATION located at County of , on the day of , 20 , at o'clock in the noon, and at any recessed Type in Injury of room or adjourned date, to testify and give evidence as a witness in this action on the part of the *This agency is requesting disclosure of your social security number in accordance with IC 22-3-4-13. This disclosure is not mandatory and you will not be penalized for refusing. Name of Physician/Prosthetician Company Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Telephone Number 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. Provide a general description of the type of prosthetic or prosthodontic requested and the work which needs to be done. Address Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney EMPLOYER INFORMATION must sign above and type name below) Date of Injury Workers Compensation Board Accident/Cause Number (if known) Name of Employer (at time of original injury) Name of Employer's Workers Compensation Carrier (if known) Street Address Attorney(s) for Street Address City State ZIP Code City Office and P.O. Address State ZIP Code Telephone No.: Facsimile No.: For initial applications only: Attach copies of any awards, agreements Workers Compensation\Second Injury Fund\Request For C:\WINNT\Profiles\Vita.001\Desktop\Indiana Update 10-03\6or other paperwork you have from your original injury. If neither E-Mail Address: you nor Repair Or have any records, please indicate this and the Board will search Prostheticthe employer Replacement From Second Injury Fund {51702}.doc its records. Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com Telephone Number Telephone Number