IN THE NEBRASKA WORKERS' COMPENSATION COURT ________________________________________________________________________ , vs. Plaintiff, _________________________________________________________________________ ________________________________________________________________________ , Defendant(s). ) ) ) ) ) ) ) ) ) ) ) DOC: NO: RELEASE OF LIABILITY PURSUANT TO NEB. REV. STAT. � 48139(3) The parties have entered into a lumpsum settlement in accordance with Neb. Rev. Stat. � 48139(1) for the injury(s) of _______________________________________________________________________, and submit this Release of Liability pursuant to Neb. Rev. Stat. � 48139(3). (Date(s) of Injury) The employer on the date(s) of injury was: ________________________________________________________________________ (Print Employer Name) ________________________________________________________________________ (Print Employer Street Address) ________________________________________________________________________ (Print Employer City, State, & Zip Code) I, ____________________________________________________________________, employee, understand and waive all rights under the Nebraska Workers' (Employee Name) Compensation Act for the abovereferenced injury(s), including, but not limited to: � � � � The right to receive weekly disability benefits, both temporary and permanent The right to receive vocational rehabilitation services The right to receive future medical, surgical, and hospital services as provided in � 48120, unless such services are specifically excluded from this release and The right to ask a judge of the compensation court to decide the parties' rights and obligations. (Employee Name) I, ____________________________________________________________________, employee, further attest and affirm that: � � � I am not eligible for Medicare, am not a current Medicare beneficiary, and do not have a reasonable expectation of becoming eligible for Medicare within thirty (30) months after the date the settlement was executed There are no medical, surgical, or hospital expenses incurred for treatment of the abovereferenced injury(s) which have been paid by Medicaid and not reimbursed to Medicaid by the employer as part of the settlement and There are no medical, surgical, or hospital expenses incurred for treatment of the abovereferenced injury(s) that will remain unpaid after this settlement. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com In consideration of payment of ____________________________ dollars in accordance with the settlement, employee agrees that the employer and its insurer are fully and completely discharged from further liability under the Nebraska Workers' Compensation Act on account of the abovereferenced injury(s). Additional provisions or documentation pertaining to this Release of Liability may be added or attached. ___________________________________________________ (Signature of Employee) ________________________________________________________ (Print Name of Employee) ________________________________________________________________________________________________________________ (Street Address, City, State, and Postal Code of Employee) ___________________________________________________ (Phone Number of Employee) State of County of _______________________________________________________________ ) _______________________________________________________________ ) ) The foregoing instrument was signed and acknowledged before me by the abovenamed individual this ________ day of _____________________________, 20_____, either personally known to me or identified by me through satisfactory evidence as required by law. Witness my hand and Notarial Seal the day and year last above written. ___________________________________________________ (Signature of Notary Public) ___________________________________________________ (Signature of Employee's Attorney) ________________________________________________________ (Print Name and Bar Niumber of Employee's Attorney) ________________________________________________________________________________________________________________ (Street Address, City, State, and Postal Code of Employee's Attorney) ___________________________________________________ (Phone Number of Employee's Attorney) State of County of _______________________________________________________________ ) _______________________________________________________________ ) ) The foregoing instrument was signed and acknowledged before me by the abovenamed individual this ________ day of _____________________________, 20_____, either personally known to me or identified by me through satisfactory evidence as required by law. Witness my hand and Notarial Seal the day and year last above written. ___________________________________________________ (Signature of Notary Public) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com