IN THE NEBRASKA WORKERS' COMPENSATION COURT , [Enter claimant's first name, middle initial, and last name] Plaintiff, vs. , [Enter name of employer or name of employer and insurance company] Defendant(s). ) ) ) ) ) ) ) ) ) DOC: NO: ORDER APPROVING LUMP SUM SETTLEMENT This matter comes on for determination upon the Application for an Order Approving Lump Sum Settlement (Application) submitted by the parties herein. The court being fully advised in the premises and having reviewed the documentation submitted, finds that the Application is made in conformity with the compensation schedule and for the best interests of the employee, and should be approved. IT IS THEREFORE ORDERED that the aforesaid Application is hereby approved. Upon payment of $____________________________, Defendant(s), its successors, and assigns shall be [Enter settlement amount here, plus any additional payments being made by defendant.] discharged from all further liability for benefits under the Nebraska Workers' Compensation Act on account of the accident and injuries on or about ______________. [Enter date(s) here] Dated at Lincoln, Lancaster County, Nebraska, on this ____ day of _______________, 20__. NEBRASKA WORKERS' COMPENSATION COURT JUDGE American LegalNet, Inc. www.FormsWorkFlow.com DOC: NO: Page 2 CERTIFICATE OF SERVICE The undersigned hereby certifies that a true and correct copy of the foregoing Order Approving Lump Sum Settlement was sent by ordinary United States mail, first class postage prepaid, on this _____ day of _________________, 20__, addressed as shown below, to the following: Clerk, Nebraska Workers' Compensation Court American LegalNet, Inc. www.FormsWorkFlow.com