Nebraska > Workers Comp
Record Request Form - Nebraska
| Record Request Form Form. This is a Nebraska form and can be used in Workers Comp . |
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Nebraska Workers Compensation Court OFFICE USE ONLYRecord Request Form Any request for public records must be written and addressed to Public Records, Nebraska Workers Compensation Court, P.O. Box 98908, Lincoln, NE 68509-8908 , or faxed to 402-471-2700 , or e-mailed to newcc@wcc.state.ne.us . This form shall be used to request records regarding injuries to an individual employee. Ample information should be provided, including: name of the employee and any previous names, social security number, date(s) of injury, date of birth, and a detailed description of the information being requested. Failure to provide this information couldresult in a delay of response and/or additional costs. Unless specifically requested, responses will be limited to first and subsequent reports filed within the last five (5) years. Suchrequests will be fulfilled within four (4) business days of receipt of this form. There will be no charge for fulfilling these requests ifsufficient information is provided to promptly identify the records. Requests for records other than first and subsequent reports filed within the last five (5) years may be subject to a charge. Theserequests may take longer than four (4) business days due to the significant difficulty or extensiveness of the request. Such requestswill be fulfilled at the earliest practicable date, and a response will exceed ten (10) business days only rarely.If fees are charged, they will be based on the actual cost of conducting the search and providing the copies. It is currently the policyof the court to charge fees if retrieval and copying costs exceed $20.00. This is subject to change at the discretion of the court. If feesare charged, an invoice will be mailed with the response. If retrieval and copying costs are estimated to exceed $50.00, the court mayrequire the requester to furnish a deposit prior to fulfilling the request. The requester will be notified in advance of fulfilling therequest if the charge is estimated to exceed $50.00. Record Search Information: Name of Injured Employee (include previous names): Social Security Number: Date(s) of Injury: Date of Birth: Please provide a detailed description of the information being requested: Requester Information: OFFICE USE ONLYName: Company: Address: City: State: Zip: Telephone: FAX: E-mail: I agree to pay charges in excess of $20.00, but not to exceed $50.00. I understand I will be notified in advance of any charge estimated to exceed $50.00. (Rev. 11/2002)
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