Publications & Forms
Please contact us with questions regarding these publications and forms. Note: The forms provided below can be completed electronically, then printed and mailed to the Nebraska Workers' Compensation Court, P.O. Box 98908, Lincoln NE 68509-8908.
Publications & Forms Index
Adjudication Publications & Forms
- Petition & Addendum 3 (Combined Form), PDF: 0.25 KB
- Addendum 3 (Individual Form), PDF: 0.25 KB
- Interpreter Selection Affidavit (Form), PDF: 0.25 KB
- Release of Liability (Form), PDF: 0.25 KB
Legal Publications & Forms
- Nebraska Workers' Compensation Laws and Rules Annotated (published by LexisNexis)
- Rules of Procedure, PDF: 0.5 MB
- Agricultural Operations & Workers' Compensation, PDF: 0.25 KB
- Rights & Obligations, PDF: 0.25 KB
- Rights & Obligations (Spanish), PDF: 0.25 KB
- Informal Dispute Resolution & Mediation, PDF: 0.25 KB
- Informal Dispute Resolution & Mediation (Spanish), PDF: 0.25 KB
- Informal Dispute Resolution Request (Form), PDF: 0.25 KB
- Information for Claimants Not Represented by an Attorney, PDF: 0.25 KB
Medical Publications & Forms
- Fee Schedules (for Medical Services, Hospital and Ambulatory Surgical Centers, Implantable Medical Devices, and Hospital Diagnostic Related Group (DRG))
- Choosing a Doctor, PDF: 0.25 KB
- Choosing a Doctor (Spanish), PDF: 0.25 KB
- Form 50: Choice of Doctor, PDF: 0.25 KB
- Form 50: Choice of Doctor (Spanish), PDF: 0.25 KB
- Independent Medical Examiner Information (PDF: 0.25 KB)
- Form 62: Independent Medical Examiner Application for Appointment, PDF: 0.25 KB
- Form 63-1: Request for Independent Medical Examiner, PDF: 0.25 KB
- Form 67-2: Notice of Agreement to Use a Named Independent Medical Examiner, PDF: 0.25 KB
Coverage and Claims Publications & Forms
- Form10T: Termination of Corporate Officer Waiver, PDF: 0.25 KB
- Form 12: Record of Compensation Insurance, PDF: 0.25 KB
- Form 12P: Record of Compensation Insurance (Intergovernmental Risk Management Pool), PDF: 0.25 KB
Vocational Rehabilitation Publications & Forms
- Vocational Rehabilitation Services, PDF: 0.25 KB
- Vocational Rehabilitation Services (Spanish), PDF: 0.25 KB
- Vocational Rehabilitation Publications & Forms
General Publications & Forms
- Annual Report (published by fiscal year)
- Statistical Report (published by calendar year)
- Occupational Surveys (published by calendar year)
- Bulletin: Since 1937 the Nebraska Workers' Compensation Court has issued its Bulletin to inform the public regarding the application and administration of the Nebraska Workers' Compensation Act (including current legislative changes), as well as information on upcoming training, seminars, and other issues.
- Order Form, PDF: 0.25 KB
- Record Request Form (a secure form that may be completed and filed electronically)
- Form 1: First Report of Alleged Occupational Injury or Illness, PDF: 0.25 KB. 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, PDF: 0.25 KB. 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.