IN THE NEBRASKA WORKERS' COMPENSATION COURT ) [Enter claimant's first name, middle initial, and last name] ) Plaintiff, ) vs. ) _________________________________ ) _________________________________ and ) _________________________________, ) [Enter name of employer or name of employer and insurance company] ) Defendant(s). ) _________________________________, IT IS AGREED BY AND BETWEEN THE PARTIES: 1. That on or about ______________ the above-named employee alleges that he/she sustained [Enter date(s) here] DOC: ____________ NO: ____________ APPLICATION FOR AN ORDER APPROVING LUMP SUM SETTLEMENT an accidental injury/occupational disease arising out of and in the course of employment with the above-named employer. 2. 3. 4. That the type of injury/illness is _________________________________________. [Enter injury/illness description here] That the circumstances surrounding the injury/illness were __________________________. [Enter circumstances here] That both the employer/insurer and employee were operating under and subject to the provisions of the Nebraska Workers' Compensation Act at the time of the alleged accident. MEDICAL EXPENSES: 5. That all medical, hospital and miscellaneous expenses incurred by employee and paid by the employer directly to the providers are listed on Attachment B -- Summary of Medical Expenses. MEDICARE: 6. [Insert the applicable employee Medicare status from the list below: Employee is not a Medicare beneficiary and does not have a reasonable expectation of becoming eligible for Medicare benefits in the next 30 months. Employee is Medicare eligible and/or a current beneficiary. Employee has a reasonable expectation of becoming Medicare eligible within 30 months. Employee's Medicare eligibility date is ______________.] [Enter date here] American LegalNet, Inc. www.FormsWorkFlow.com 7. [Include this paragraph if claimant is a current Medicare beneficiary: A conditional payment investigation through the Centers for Medicare and Medicaid Services has [not] been completed, and the employer will reimburse Medicare for conditional payments made by Medicare or the employer will reimburse Medicare an amount agreed to by Medicare in satisfaction of its interests regarding such payments, if any exist.] 8. The parties have considered Medicare's interests and have determined that defendant will fund a Medicare Set Aside in the amount of $______________. [Enter dollar amount here, even if it is zero dollars ($0.00)] VOCATIONAL REHABILITATION: 9. That employee understands his/her rights to undergo rehabilitation but is waiving any further entitlement to vocational rehabilitation benefits for one of the following reasons: Employee has returned to suitable work. Wage rate: $ ___________________________ [Enter dollar amount here] Employer: ___________________________ [Enter employer here] Job title/type of work: ___________________________ [Enter job title/type of work here] Starting date: ___________________________ [Enter starting date here] Employee has not returned to suitable work but nevertheless wishes to enter into this settlement. Waivers are closely scrutinized by the court and in most cases will not be approved if the employee has not returned to suitable employment. See Attachment C -- Explanation of Waiver of Vocational Rehabilitation. DISABILITY COMPENSATION: See Attachment A -- Computation Form 10. Average Weekly Wage: a. Employee's average weekly wage on the date of injury was $______________. [Enter dollar amount here] b. Employee's wage rate (per hour, day or output) on the date of injury was $______________. [Enter dollar amount here] 11. Temporary Benefits: a. ________________________________________. [Enter comments here regarding TTD claimed/paid] b. ________________________________________. [Enter comments here regarding TPD claimed/paid] American LegalNet, Inc. www.FormsWorkFlow.com 12. Permanent Benefits: ________________________________________. [Enter comments here regarding PPD/PTD/LOE claimed/paid] The employee understands that by entering into this settlement, the employee: will not receive any further workers' compensation benefits including temporary or permanent disability, vocational rehabilitation, and medical, hospital or miscellaneous expenses by reason of this injury/illness; may decline settlement and proceed to trial, which may result in more or less money and other benefits or dismissal of employee's claim; and understands that upon payment of the court-approved amount of $__________________________ [Enter settlement amount here, plus any additional payments being made by defendant] by defendant as detailed in in Attachment A, employer, its insurer, their successors and assigns, are fully discharged from all further liability to employee under the Nebraska Workers' Compensation laws, as amended, on account of the accident and injury(ies) of ___________________________, [Enter date(s) of injury here] whether now known or to become known in the future, whether physical or mental, unless the settlement was procured by fraud, and shall be entitled to a duly executed release. Upon filing the release or other proof of payment with the court, the liability of the employer under any agreement, award, finding or decree under the Nebraska Workers' Compensation laws, as amended, shall be discharged of record. This lump sum settlement application is submitted to the Nebraska Workers' Compensation Court for approval as provided by law and it is understood that this lump sum settlement shall be null and void unless approved by the Court. EMPLOYEE COMMENTS: _______________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ EMPLOYER COMMENTS: _______________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com _