Free petition_draft_20090126.pmd - Nebraska

In The Nebraska Workers' Compensation Court
_______________________________________________________________________ (your first name, middle initial, and last name)

Leave This Section Blank. For Court Use Only.

Plaintiff,

Docket

____________________

vs.
_______________________________________________________________________ (name of employer or name of employer and insurance company)

Page ____________________

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. ____________________________________________________________________

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 two-year 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 800-599-5155 or 402-471-6468 or contact the court by e-mail 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 REPRESENT THAT THESE INSTRUCTIONS AND FORMS WILL BE APPROPRIATE IN EVERY CASE. ANY QUESTIONS YOU MAY HAVE REGARDING THE USE OF THE INSTRUCTIONS AND FORMS SHOULD BE DIRECTED TO A LAWYER. HEADING · Enter your current first name, middle initial, and last name. · Enter the name of your employer at the time of the injury. If you know the name of your employer's insurance company, you may list it (in addition to the employer's name). · Leave the Docket and Page lines blank. The Clerk of the Workers' Compensation Court will give the petition a docket and page number and will fill in those lines. The docket number is used to identify your case. You may contact the Clerk's office after you file the petition to obtain your docket and page number. BODY OF THE PETITION Paragraph 1. Enter the date of the accident. If you are unsure of the exact date of the accident, estimate the date as closely as possible. Enter the name of the county and state where the accident happened. Paragraph 2. Enter your job title at the time of injury. Enter your weekly wage or estimate your wage as closely as possible. Describe the body part(s) that was injured. Enter the date the employer had notice or knew about the injury, or estimate the date as closely as possible. Describe how the accident happened. Paragraph 3. Enter the areas of disagreement (such as whether the injury was work-related, extent of disability, whether the claimant was an employee, payment of medical bills, fees or penalties claimed, vocational rehabilitation, or any other issues the parties do not agree on). ADDRESS AND SIGNATURE · Print the address of the employer (and the employer's insurance company or any other defendant you listed in the heading). · Sign your name on the first line. · Print your full name on the second line, as you entered it in the heading. · Print your telephone number. · Print your address. Note: If your address or phone number changes, contact the Clerk's office to ensure that you will continue receiving important notifications about your case. Make a copy (or copies) of the petition and send the original and the copy(s) to the court. The original is for the court file, and each additional copy is for every defendant you listed in the heading. The court will send the copy(s) to the defendant(s). For example, if you only listed the employer, the original and one copy of the petition must be given to the court (original for the court and one copy for the employer). If you listed the employer and the employer's insurance company, the original and two copies of the petition must be given to the court (original for the court, one copy for the employer, and one copy for the insurance company). You should also keep a copy for your records. You may mail, fax, or hand-deliver the forms. Mail to: Nebraska Workers' Compensation Court P.O. Box 98908 Lincoln NE 68509-8908 Fax to: 402-471-8231 Hand-deliver (or deliver by FedEx, UPS, etc.) to: Nebraska Workers' Compensation Court State Capitol Building, 13th Floor 1445 `K' Street Lincoln, NE 68508

ADDENDUM 3 INSTRUCTIONS HEADING · Print your current first name, middle initial and last name. · Print the name of your employer or your employer and its insurance company the same way you entered them on the petition. · Provide your Social Security number. · If necessary for your case, enter the names, Social Security numbers, and birth dates of any minor children. An example of when this information might be needed is when the family makes a claim for death benefits because the employee died. · If necessary for your case, enter the financial account information. YOU MUST provide a completed Addendum 3 to the court when you file your petition. The purpose of this document is to protect private information. This information will not appear in public court documents. In most cases you will only provide your Social Security number on this form.

IN THE NEBRASKA WORKERS' COMPENSATION COURT THIS DOCUMENT IS CONFIDENTIAL AND SHALL NOT BE MADE PART OF THE COURT FILE OR PROVIDED TO THE PUBLIC PURSUANT TO WORKERS' COMP. CT. R. OF PROC. 2. __________________________________, Plaintiff, ) ) ) ) ) ) ) ) ) ) DOC: NO:

PERSONAL AND FINANCIAL ACCOUNT INFORMATION

vs. __________________________________, Defendant.

Employee Social Security Number Employee Date of Birth (if applicable to this case)

___________________ ___________________

Minor Children (if applicable to this case) Name __________________ __________________ __________________ Social Security Number _____________________ _____________________ _____________________ Date of Birth ___________ ___________ ___________

Protected financial account information (if applicable to this case) Entity/Person Type of Account Account Number

________________

__________________

___________________

(add additional pages as necessary)

Addendum 3