(Rev. 07/2010) NEBRASKA WORKERS’ COMPENSATION COURT ORDER FORM SEND ORDER TO: Nebraska Workers’ Compensation Court P. O. Box 98908 Lincoln, NE 68509-8908 Name _____________________________________________ Company Name _____________________________________ Telephone: 402-471-6468 or 800-599-5155 Fax: 402-471-2700 Web site: http://www.wcc.ne.gov Address ___________________________________________ ___________________________________________ FOR OFFICE USE ONLY: Paid by: Check ________________ Cash ________________ Mailed ________________ Picked Up ________________ ________________________ ______ __________ (City) (State) (Zip Code) Phone (_______) ____________________________________ Note: All publications and forms produced by the Nebraska Workers’ Compensation Court may be downloaded at no charge from our web site (http://www.wcc.ne.gov/publications.htm). Single Forms (Limit of 10 per order — Copies can be made) # SGL Form Number / Item Name # SGL Form 1—First Report of Injury / Illness (Rev. 11/2006) Form Number / Item Name Form 4—Subsequent Report (Rev. 06/2006) Form 12—Insurance Coverage (Rev. 06/1995) Single Pamphlets or Packages of 25 (Limit of 4 Packages) # SGL # PKG (25) Item Name # SGL # PKG (25) Item Name Rights & Obligations - English (Rev. 04/2010) Vocational Rehabilitation Services - English (Rev. 02/2001) Rights & Obligations - Spanish (Rev. 04/2010) Vocational Rehabilitation Services - Spanish (Rev. 05/2001) Choosing a Doctor - English (Rev. 11/1999) Informal Dispute Resolution & Mediation – English (Rev. 01/2001) Choosing a Doctor - Spanish (Rev. 11/1999) Informal Dispute Resolution & Mediation – Spanish (Rev. 01/2001) Single Forms # SGL Form Number / Item Name # SGL Form Number / Item Name Informal Dispute Resolution Request (Rev. 08/2000) Form 50—Choice of Doctor - English (Rev. 01/1997) Petition (Rev. 01/2009) Form 50—Choice of Doctor - Spanish (Rev. 08/1997) Addendum 3 (Rev. 01/2009) Form 62—IME Application for Appointment (Rev. 03/2009) Release of Liability (Rev. 06/2009) Form 63-1—Request for IME (Rev. 09/2001) Form 10T—Termination of Corporate Officer Waiver (Rev. 12/1996) Form 67-2—Notice of Agreement to Use a Named IME (Rev. 07/1997) Other Publications Law Book (Includes 2006 Legislative Revisions) only available from LexisNexis at 800-562-1197 or from their web site (http://www.lexisnexis.com). Forms may be picked up at the Nebraska Workers’ Compensation Court, 13th Floor, State Capitol Building. Please call ahead to be sure your order is ready. For further information, or if your order is not received within three weeks, please contact the court’s information line at either 402-471-6468 or 800-599-5155. American LegalNet, Inc. www.FormsWorkFlow.com