Last updated: 9/24/2025
Application For An Order Approving Lump Sum Settlement
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Description
APPLICATION FOR AN ORDER APPROVING LUMP SUM SETTLEMENT. This is a Nebraska Workers’ Compensation Court form used when an employee and employer/insurer agree to settle a workers’ compensation claim for a one-time payment. Required under Neb. Rev. Stat. § 48-139 and Court Rule 47, the form documents the circumstances of the injury, average weekly wage, temporary and permanent disability benefits, attorney fees, and settlement amount. It also addresses outstanding medical expenses, reimbursement responsibilities, Medicare interests, and vocational rehabilitation rights. Attachments include a Lump Sum Settlement Computation Form (Attachment A) and an Itemized Medical Expense Summary (Attachment B). The settlement is not effective unless approved by the Court, which reviews waivers, medical reports, and compliance with statutory safeguards. www.FormsWorkflow.com
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