IN THE NEBRASKA WORKERS' COMPENSATION COURT _____________________________________________________________________ (your first name, middle initial, and last name) , Leave This Section Blank. For Court Use Only. vs. Plaintiff, , Docket ____________________ Page ____________________ _____________________________________________________________________ (name of employer or name of employer and insurance company) Defendant. PETITION Comes now the plaintiff and for cause of action against the defendant alleges and avers: 1. That on or about ________________________________________________________ the plaintiff sustained personal injury in an accident arising (date of accident) out of and in the course of the plaintiff's employment by the defendant, which accident occurred in ________________________________________ (county where accident happened) County, State of ________________________________________ for which injury the plaintiff is entitled to compensation from the defendant. (state where accident happened) 2. That at the time of said accident the plaintiff was employed as ______________________________________________________________ and was (type of job) receiving salary or wages, or other earnings from the defendant of approximately $ _______________________ per week. That the extent and (weekly wage) character of the injury sustained was __________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________ (describe the injury) and that the employer had notice and knowledge of said accident and injury on or about ___________________________________________________ (date employer notified) That said accident and injury occurred in the following manner: ______________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________ (describe the accident) 3. The matter or matters in dispute are ____________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________ (list of benefits in dispute) 4. WHEREFORE, the plaintiff prays that a hearing be had before the Nebraska Workers' Compensation Court and that the rights and liabilities of the parties be determined by said court and that the plaintiff be awarded such benefits as he or she may be entitled to under the provisions of the Nebraska Workers' Compensation Law. _______________________________________________________________________ (print employer street address) _______________________________________________________________________ (print employer city, state, & zip code) _______________________________________________________________________ (print insurer street address, if applicable) _______________________________________________________________________ (print insurer city, state, & zip code, if applicable) _______________________________________________________________________ (print additional defendant street address, if applicable) _______________________________________________________________________ (print additional defendant city, state, & zip code, if applicable) _______________________________________________________________________ (sign your name) _______________________________________________________________________ (print your full name as listed above) _______________________________________________________________________ (print your telephone number) _______________________________________________________________________ (print your street address) _______________________________________________________________________ (print your city, state, & zip code) Note: See other side for instructions. Please keep the court informed if you change your address or phone number. American LegalNet, Inc. www.FormsWorkFlow.com PETITION PROCEDURES If you believe that you were denied rights under the Workers' Compensation Act and if you wish to take legal action to pursue your claim further, you may start a formal litigation process by filing a petition. This means you are filing a lawsuit against someone. If you file the lawsuit, you will need to be prepared to present your case in a formal trial before a judge of the Workers' Compensation Court. You may file the petition yourself and act on your own without an attorney, or you may hire an attorney to represent you. It is your choice to hire an attorney or to represent yourself. If you choose to file a petition, you must file it within two years of the date of the accident or the date of the last payment of workers' compensation benefits. If you do not file before the twoyear time limit, your claim may be dismissed with no benefits payable to you. This time limit is called the Statute of Limitations. You or your attorney must file an original and one or more completed copies of the petition with the court (see petition instructions). You should also keep a copy for your records. After your petition is filed, the other side has two weeks from the date they received notice of the lawsuit to file an Answer with the court. Once you file the lawsuit, you will likely receive correspondence and/or requests for information from the court and from the defendant. Be sure to respond to requests for information in a timely manner. The case will then be scheduled for a hearing before a judge. Hearings generally are held in the county where the claimed injury happened. That hearing location can be changed if the parties agree and the court approves the agreement. Additional questions regarding the petition process may be directed to the court's Information Line at 8005995155 or 4024716468 or contact the court by email from our web site (http://www.wcc.ne.gov/). PETITION INSTRUCTIONS These instructions and forms are a product of the Nebraska Workers' Compensation Court and are provided as a public service to people who wish to file a lawsuit to pursue workers' compensation benefits. THE WORKERS' COMPENSATION COURT DOES NOT REPRESE