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Nebraska Form Center -

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Form

Description

form1.pdf First Report of Alleged Occupational Injury or Illness
form4.pdf Subsequent Report
petition.pdf Petition & Addendum
motion_proposed_order_continue.pdf Motion to Continue Trial - Order of Continuance
int-sel-aff.pdf Interpreter Selection Affidavit
settlement_application.pdf Application for an Order Approving Lump Sum Settlement
proposed_order.pdf Proposed Order Approving Lump Sum Settlement
liability_release.pdf Release of Liability
rightsobligations.pdf BROCHURE - Rights & Obligations under the Nebraska Workers' Compensation Law
rightsobligations-sp.pdf BROCHURE - Rights & Obligations under the Nebraska Workers' Compensation Law (Spanish)
idrform.pdf Informal Dispute Resolution Request Form
idr_info_sheet.pdf Information Sheet: Informal Dispute Resolution and Mediation
choosedoctor.pdf Information Sheet - Choosing a Doctor for a Work-Related Injury
choosedoctor-sp.pdf Information Sheet - Choosing a Doctor for a Work-Related Injury (Spanish)
form50.pdf Choice of Doctor
form50-sp.pdf Choice of Doctor (Spanish)
form62.pdf Independent Medical Examiner Application for Appointment
form63-1.pdf Request for Independent Medical Examiner
form67-2.pdf Notice of Agreement to use a Named Independent Medical Examiner
form10t.pdf Termination of Corporate Executive Officer Waiver
form12.pdf Record of Compensation Insurance
form12p.pdf Record of Compensation Insurance - Intergovernmental Risk Management Pool
vrservices.pdf BROCHURE - Vocational Rehabilitation Services under the Nebraska Workers' Compensation Law
vrservices-sp.pdf BROCHURE - Vocational Rehabilitation Services under the Nebraska Workers' Compensation Law (Spanish)
vr37e1.pdf Case Closure Report- No Plan Proposed
vr37e2.pdf Case Closure Report - Plan or Plans Proposed
vr37e3.pdf Plan Closure Report
vr37e4.pdf Follow-Up Employment Status Report
vr39.pdf Application for Certification Vocational Rehabilitation
vr39a.pdf Application for Renewal of Certification Vocational Rehabilitation
vr42.pdf Vocational Rehabilitation Counselor Designation
vr42b.pdf Vocational Rehabilitation Counselor Appointment Request
vr42c.pdf Agreement for the Selection of a Vocational Rehabilitation Counselor
vr42c-sp.pdf Agreement for the Selection of a Vocational Rehabilitation Counselor (Spanish)
vr43.pdf Request for Change of Vocational Rehabilitation Counselor
vr44.pdf Vocational Rehabilitation Plan
us_citizenship_attestation.pdf US Citizenship Attestation Form
us_citizenship_attestation-sp.pdf US Citizenship Attestation Form (Spanish)
vr44s.pdf Supplemental Billing Request
vr44_sia.pdf Student Information and Instructions
vr44_sib.pdf Job Placement Information and Instructions
vr44_sic.pdf Supportive Services Student Information and Instructions
vr44_sic-sp.pdf Supportive Services Student Information and Instructions (Spanish)
vr44_sid.pdf Supportive Services Student Information and Instructions
vr44_sid-sp.pdf Supportive Services Student Information and Instructions (Spanish)
2017_js_mileage.pdf Job Search Activity Log - Travel after 01/01/2017
2016_js_mileage.pdf Job Search Activity Log - Travel after 01/01/2016
2015_js_mileage.pdf Job Search Activity Log - Travel after 01/01/2015
2014_js_mileage.pdf Job Search Activity Log - Travel after 01/01/2014
2013_js_mileage.pdf Job Search Activity Log - Travel from 01/01/2013 through 12/31/2013
2012_js_mileage.pdf Job Search Activity Log - Travel from 07/01/2011 through 12/31/2012
2011_js_mileage.pdf Job Search Activity Log - Travel from 01/01/2011 through 06/30/2011
Pre2011_js_mileage.pdf Job Search Activity Log - Travel prior to 01/01/2011
2017_ged_mileage.pdf GED,ELL,ABE Training Mileage - travel after 01/01/2017
2016_ged_mileage.pdf GED,ELL,ABE Training Mileage - travel after 01/01/2016
2015_ged_mileage.pdf GED,ELL,ABE Training Mileage - travel after 01/01/2015
2014_ged_mileage.pdf GED,ELL,ABE Training Mileage - travel after 01/01/2014
2013_ged_mileage.pdf GED,ELL,ABE Training Mileage - travel from 01/01/2013 through 12/31/2013
2012_ged_mileage.pdf GED,ELL,ABE Training Mileage - travel from 07/01/2011 through 12/31/2012
2011_ged_mileage.pdf GED,ELL,ABE Training Mileage - travel from 01/01/2011 through 06/30/2011
Pre2011_ged_mileage.pdf GED,ELL,ABE Training Mileage - travel prior to 01/01/2011
2017_training_mileage.pdf Formal Training Mileage Reimbursement - travel on and after 01/01/2017
2016_training_mileage.pdf Formal Training Mileage Reimbursement - travel on and after 01/01/2016
2015_training_mileage.pdf Formal Training Mileage Reimbursement - travel on and after 01/01/2015
2014_training_mileage.pdf Formal Training Mileage Reimbursement - travel on and after 01/01/2014
2013_training_mileage.pdf Formal Training Mileage Reimbursement - travel from 01/01/2013 through 12/31/2013
2012_training_mileage.pdf Formal Training Mileage Reimbursement - travel from 07/01/2011 through 12/31/2012
2011_training_mileage.pdf Formal Training Mileage Reimbursement - travel from 01/01/2011 through 06/30/2011
Pre2011_training_mileage.pdf Formal Training Mileage Reimbursement - travel prior to 01/01/2011
mileage_reimb_one-way.pdf Special One-Way Mileage Reimbursement Form
monthly_tutor_payment.pdf Monthly Tutor Payment Form
progress_report.pdf Instructors Monthly Progress Report
study_program.pdf Program of Study
praecipe_transcript.pdf Praecipe for Transcript
notice_appeal.pdf Notice of Appeal
boe_request.pdf Request for Bill of Exceptions
affidavit_application_payment.pdf Affidavit and Application to Proceed Without Payment of Costs
postinfo.pdf Posters are only required for certain agricultural operations. If you are agricultural check posting requirements above.