Informal Dispute Resolution (IDR) (402) 471-6468 (Lincoln area & out-of-state) Workers’ Compensation Court State of Nebraska P. O. Box 98908 Lincoln, NE 68509–8908 (800) 599-5155 (Nebraska only) Injured Employee: Name: Social Security #: Address: Phone #: ( ) Fax #: ) Attorney if represented: ( Phone #: Fax #: ( ) Fax #: ( ) Fax #: ( ) Employer: Contact Name: Company: Address: Phone #: ( Fax #: ( ) Phone #: ( ) Phone #: ( ) Fax #: ( ) Phone #: ( Attorney if represented: ) ) Insurer: Contact Name: Company: Address: Attorney if represented: Nature of the dispute: In order to prepare both parties, please answer as many of the following questions as possible that apply to the current situation. Write N/A in the blank to those questions that do not apply. Attach a written explanation in addition to the answers below if necessary. Please copy this form and any attachments and send to the court (attn: mediation coordinator) and to the other party(s). Send only copies of attachments. Originals will not be returned. Information not to be disclosed to the other party(s) may be sent to the court, but please indicate it is confidential. If you have any questions, please call the mediation coordinator. 1. What is the date(s) of injury(s)? Attach a copy of the First Report(s) of Injury if available. 2. Has this dispute ever been submitted to the court? 3. Explain briefly how the accident or injury occurred. 4. Has the worker missed any time from work due to the injury? If so, please give docket/page number: If so, please specify days or parts of days. Please See Other Side for Additional Questions American LegalNet, Inc. www.FormsWorkflow.com NWCC IDR Rev. 8/00 5. Has the worker returned to work? same employer. If so, state the type of work, date started, salary and whether it is with the 6. If the worker hasn’t returned to work, does he or she feel capable of returning to suitable and gainful employment with previous training and skills? 7. Did a doctor prohibit the worker from working or request restricted or light duty? from the doctor if possible. 8. What was the average weekly wage at the time of injury? 9. Has a doctor stated that the worker is at “maximum medical improvement” or anything similar? note/report from the doctor if possible. 10. Has a doctor assigned an impairment rating or disability rating? Attach a copy of the note/report from the doctor if possible. If so, what Attach a copy of the note/report Attach a copy of the % and part of body: 11. Has a Loss of Earning Power Evaluation been performed by any vocational rehabilitation counselor? the report if possible. 12. Are there outstanding medical bills? Attach a copy of If so, please summarize on a one-page list and attach copies of each. 13. Is the employee under a Managed Care Plan for workers’ compensation? plan been exhausted? 14. What has the employee and what has the employer or insurer paid for at this point? If so, has the grievance procedure under the Attach summary sheet if necessary. 15. Are there any other people who will participate in the mediation conference with you? Issue(s) in dispute: Please explain in detail the issue(s) in dispute. If the insurer has denied the claim please attach a copy of the denial letter. Desired outcome: List any specific action you would like taken. List any monetary amount you desire paid to you, or which you have already paid and the basis for this amount. Signature Date American LegalNet, Inc. www.FormsWorkflow.com