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Nebraska Workers' Compensation Legal Library


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ADDENDUM3
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.
[loor first name, middle initial and last name]
Plaintiff,
vs.
[name of employer or name of employer and insurance company
Defendant{s).
Docket: ___ _ Page: ___ _
PERSONAL AND FINANCIAL
ACCOUNT INFORMATION
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 addiaonal pages as necessary)
Addendum3



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