Free Order Form - Nebraska

(Rev. 01/2008)

Nebraska Workers' Compensation Court

ORDER FORM
Ship To:
Name _____________________________________________ Company Name _____________________________________ Address ___________________________________________ ________________________ ______ __________ City) (State) (Zip Code) Phone (_____) ______________________________________ Nebraska Workers' Compensation Court P. O. Box 98908 Lincoln, NE 68509-8908 Telephone: 402-471-6468 or 800-599-5155 Fax: 402-471-2700 Website: http://www.wcc.ne.gov/ OFFICE USE ONLY Paid by: Check ________________ Cash ________________ Mailed ________________ Picked Up ________________

Note: Many of the items below are available on our website (http://www.wcc.ne.gov/pubs.htm) for downloading and printing.
Single Forms (Limit of 10 per order -- Copies can be made)
# SGL Form Number / Item Name # SGL Form Number / Item Name

Form 1--First Report of Injury / Illness (Rev. 11/2006) Form 12--Insurance Coverage (Rev. 06/1995)

Form 4--Subsequent Report (Rev. 06/2006)

Single Pamphlets or Packages (Limit of 4 Packages)
# SGL # PKG Item Name

(25) (25) (25) (25) (25) (25) (25)

Rights & Obligations (English 01/2008) Rights & Obligations (Spanish 01/2008) Choosing a Doctor for a Work-Related Injury (English 11/1999) Choosing a Doctor for a Work-Related Injury (Spanish 11/1999) Vocational Rehabilitation Services under Workers' Compensation (English 02/2001) Vocational Rehabilitation Services under Workers' Compensation (Spanish 05/2001) Informal Dispute Resolution and Mediation (English 01/2001) Single Forms

Quantity

Form Number/Item Name

Quantity

Form Number/Item Name

Form 10T--Termination of Corporate Officer Waiver (Rev. 12/1996) Form 63-1--Request for Independent Medical Examiner (09/2001)

Form 50--Choice of Doctor (English 01/1997) Form 50--Choice of Doctor (Spanish 08/1997)

Form 67-2--Notice of Agreement to use a Named Independent Medical Examiner (07/1997) Other Publications Law Book (Includes 2006 Legislative Revisions) only available from LexisNexis at 800-562-1197 or from their website (http://bookstore.lexis.com/bookstore). All other court publications may be downloaded, at no charge, from our website (http://www.wcc.ne.gov/pubs.htm).

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. Order forms and other information may also be downloaded from the court's website (http://www.wcc.ne.gov/pubs.htm). 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.