Application For Second Injury Fund Benefits {51247}

COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No.PRIVACY NOTICE Indiana Worker's Compensation Board *This agency disclosure Application for Second Injury Fund Benefits Calendar No. is requestingnumber in : of your Social Security State Form 51247 (2-03) Accident Number Plaintiff(s) Instructions: This form must be submitted in duplicate to: Indiana Workers Compensation Board 402 W. Washington, RM W196, Indianapolis, IN 46204-2753 -against: : : Address State : JUDICIAL SUBPOENA accordance with IC 22-3-4-13. This disclosure is not mandatory and you will not be penalized for refusing. CLAIMANT INFORMATION Social Security Number * Date of Birth Last Name City First Middle Defendant(s) : . . . . . . . . . . . . . . . . . . . . . .Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... Zip ( ) THE PEOPLE OF THE STATE OF NEW YORK INFORMATION INJURY Date of Injury Disputed Cause # Date of Award Type of Injury/Illness Part of Body TO Briefly describe the injury in your own words GREETINGS: WE COMMAND YOU, that all fund payments for this being laid ¨ Check here if you have received any second injury business and excusesaccident. aside, you and each of you attend before As the injured party requesting benefits of the second injury fund administered by the Indiana Worker's Compensation fund, I do hereby , the Honorable at the Court located at County of in room , on the day of CLAIMANT'S AFFIDAVIT o'clock in the , 20 , at noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the solemnly swear and affirm that the information given in this application is a true and accurate representation of the information regarding my work-related injury, as witnessed on this ___________day of ___________________, two thousand and _____________________. Notary Seal Notary Signature Applicant Signature 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. , one of the Justices of the , 20Applicant Printed Name Date (Attorney must sign above and type name below) Prepared Witness, Honorable Court in County, day of Notary Printed Name Notary Commission Expiration Date APPLICATION CHECKLIST Attorney(s) for In order to proceed in processing this application, The Board must receive from you the following items (Please Check): ¨ This completed application is signed and notarized ¨ A current copy of the applicant's medical report. ¨ Form submitted in duplicate Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com