Court Forms and Publications
This page contains links to forms and publications produced by the Nebraska Workers’ Compensation Court, grouped by subject area.
The forms can be completed electronically, then printed and mailed to the Nebraska Workers’ Compensation Court, P.O. Box 98908, Lincoln NE 68509-8908.
Please contact us with questions regarding these forms and publications.
Legal and Self-Representation
Legal and Self-Representation
NOTE: The Nebraska Supreme Court’s Legal Self-Help Center offers general guidance for appearing in court.
- Petition and Addendum 3 (Combined Form)
- Addendum 3 (Individual Form)
- Answer to Petition
- Motion to Continue Trial and Proposed Order of Continuance (Combined Form)
- Interpreter Selection Affidavit
- Settlement Application. NOTE: The statutory filing fee is $15.00; pay to the order of “Nebraska Workers’ Compensation Court.”
- Release of Liability. NOTE: The statutory filing fee is $15.00; pay to the order of “Nebraska Workers’ Compensation Court.”
- Overview of Appeal to the Nebraska Court of Appeals
- Nebraska Workers’ Compensation Laws and Rules Annotated (published by LexisNexis)
- Rules of Procedure
- Rights and Obligations
- Rights and Obligations (Spanish)
- Informal Dispute Resolution and Mediation
- Informal Dispute Resolution and Mediation (Spanish)
- Informal Dispute Resolution Request
- Information for Claimants Not Represented by an Attorney
- Information for Claimants Not Represented by an Attorney (Spanish)
General
General
- Employee Frequently Asked Questions
- Employer Frequently Asked Questions
- Health Insurance Portability and Accountability Act (HIPAA)
- Annual Report (published by fiscal year)
- Statistical Report (published by calendar year)
- Bureau of Labor Statistics Reports (published by calendar year)
- Record Request Form (a secure form that may be completed and filed electronically)
Vocational Rehabilitation
Vocational Rehabilitation
- Vocational Rehabilitation Services
- Vocational Rehabilitation Services (Spanish)
- Other Vocational Rehabilitation Forms and Publications
Regulatory Programs
Regulatory Programs
Coverage
Coverage
- Agricultural Operations and Workers’ Compensation
- Form 12: Record of Compensation Insurance,
- Form 12P: Record of Compensation Insurance (Intergovernmental Risk Management Pool)
Medical
Medical
- Fee Schedules
- Choosing a Doctor for a Work-Related Injury
- Choosing a Doctor for a Work-Related Injury (Spanish)
- Form 50: Choice of Doctor
- Form 50: Choice of Doctor (Spanish)
- Independent Medical Examiner Frequently Asked Questions:
- Form 62: Independent Medical Examiner Application for Appointment
- Form 63-1: Request for Independent Medical Examiner
- Form 67-2: Notice of Agreement to Use a Named Independent Medical Examiner
Claims
Claims
- Form 1: First Report of Alleged Occupational Injury or Illness. NOTE: Companies that have signed a Trading Partner Agreement with the Nebraska Workers’ Compensation Court may use this form only with the court’s permission.
- Form 4: Subsequent Report. NOTE: Companies that have signed a Trading Partner Agreement with the Nebraska Workers’ Compensation Court may use this form only with the court’s permission.