Free release_draft2_20090604.pmd - Nebraska

IN THE NEBRASKA WORKERS' COMPENSATION COURT
) ____________________________________________________________________ ) Plaintiff, ) ) vs. ) ____________________________________________________________________ ) ) ) ____________________________________________________________________ Defendant(s). ) ) ) DOC: NO:

RELEASE OF LIABILITY PURSUANT TO NEB. REV. STAT. § 48-139(3)

The plaintiff and defendant(s) have entered into a lump-sum settlement in accordance with Neb. Rev. Stat. § 48-139(1) for the injury(s) of
____________________________________________________________________, and submit this Release of Liability pursuant to Neb. Rev. Stat. § 48-139(3). (date(s) of injury)

I, ____________________________________________________________________, plaintiff, understand and waive all rights under the Nebraska Workers'
(plaintiff name)

Compensation Act for the above-referenced 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 § 48-120, 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.

·

I, ____________________________________________________________________, plaintiff, further attest and affirm that:
(plaintiff name)

·

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 above-referenced 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 above-referenced injury(s) that will remain unpaid after this settlement.

·

·

In consideration of payment in accordance with the settlement, plaintiff 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 above-referenced injury(s). Additional provisions or documentation pertaining to this Release of Liability may be added or attached.

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____________________________________________________________________

Plaintiff
____________________________________________________________________ ____________________________________________________________________

Address State of ___________________________________________ ) ) County of ___________________________________________ ) The foregoing instrument was signed and acknowledged before me by the above-named 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.
____________________________________________________________________

Notary Public

____________________________________________________________________

Plaintiff's Attorney
____________________________________________________________________ ____________________________________________________________________

Address State of ___________________________________________ ) ) County of ___________________________________________ ) The foregoing instrument was signed and acknowledged before me by the above-named 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.
____________________________________________________________________

Notary Public

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