Release of Liability Procedures — General
Neb. Rev. Stat. § 48-139(1)(a) lists the factors that determine whether a Lump Sum Settlement Application must be submitted to the Worker’s Compensation Court for review, or whether the parties may submit a Release of Liability (release).*
The parties shall use only this form, which has been approved by the Nebraska Workers’ Compensation Court pursuant to Neb. Rev. Stat. § 48-139. Other than an itemized list of medical expenses incurred as a result of the alleged accident(s) and injury(s), no additional documents may be filed with this form. Failure to abide will result in your filing being rejected.
A release cannot be filed if:
The employee is not represented by counsel;
The employee, at the time the settlement is executed, is eligible for Medicare, is a Medicare beneficiary, or has a reasonable expectation of becoming eligible for Medicare within 30 months after the date the settlement is executed;
Medical, surgical, or hospital expenses incurred for treatment of the injury have been paid by Medicaid and Medicaid will not be reimbursed as part of the settlement;
Medical, surgical, or hospital expenses incurred for treatment of the injury will not be fully paid as part of the settlement; or
The settlement seeks to commute amounts of compensation due to dependents of the employee.
Filing Fee:
A $15.00 filing fee must be included with the release.
Other Filing Instructions:
If the case has not previously been assigned a docket number, an Addendum 3 must be submitted with the release.
Section 48-139(4) of the Act requires an order of dismissal to be entered on all cases in which a release of liability is filed. Also, Rule 47(J) requires the parties to file a receipt, satisfaction, or joint stipulation for dismissal on all such cases.
The receipt, satisfaction, or joint stipulation for dismissal does not need to accompany the release of liability and can be filed after the employer has made payment to the employee. Upon filing of the receipt, satisfaction, or joint stipulation for dismissal, the parties must submit a proposed order of dismissal to the clerk’s office as an email attachment to the following email address:
