Settlement Application and Proposed Order Approving Lump Sum Settlement
This page contains links to software provided by the Nebraska Workers’ Compensation Court. The Settlement Application and Proposed Order forms may be downloaded and stored for future use or accessed directly from our website.
These forms are a product of the Nebraska Workers’ Compensation Court and are provided to assist in preparing a lump sum settlement application. The court does not represent that these forms will be appropriate in every case. Questions pertaining to the functionality of these forms may be directed to the court’s Legal section. Please note, however, that we cannot provide legal advice or a legal opinion.
The contents herein are provided on an “as is” and “as available” basis. The court will not be liable for any loss, injury, or damage incurred as a consequence, directly or indirectly, of the use or application of the contents herein. We will not be liable for direct, special, incidental, or consequential damages, even if advised of the possibility of such damages.
The Nebraska Workers’ Compensation Court does not mandate use of a specific lump sum settlement application form. However, the settlement application form below has the information required by Rule 47 and contains language that is generally approved by the court.
In some sections, you may need to delete or add language as necessary to suit your circumstances. For example, in Paragraph 6, you should choose the appropriate Medicare status statement, and delete the statements that do not apply.
- In an application leaving defendant’s liability open for medical expenses, the caption and body of the application should reflect that medical liability is being left open and should include the statement required by Rule 47,B,5 “that in the event that a dispute arises as to payment of a medical expense, the parties may submit the matter to a judge of the compensation court for a determination.”
- Every application should provide the claimant’s Medicare status.
- If the employee is a Medicare beneficiary, the application must state whether a conditional payment investigation has been completed (yes or no) and must include the conditional payment reimbursement language required by Rule 47,B,12. This is true even when an application is leaving medical liability open. If an application is filed under LB953, the party’s description of the agreement relating to Medicare should include the agreement regarding conditional payments.
- In every application where the claimant is represented, the application should provide the amount of attorney fees and costs.
- The itemized list of medical expenses must include payments made by Medicaid.
Download Settlement Application and Proposed Order Approving Lump Sum Settlement
NOTE: The statutory filing fee is $15.00; pay to the order of “Nebraska Workers’ Compensation Court.”
NOTE: Regarding the links to both Microsoft Word files below, clicking the link will display the file in a new web browser window. To download the file onto your computer, select the down-pointing arrow in the top right corner of the screen. You may also select the “Open with Google Docs” option in the top center of the screen if you prefer to use that format rather than the Word format in which it was created.)