IN THE DISTRICT COURT OF ___________________________ COUNTY, NEBRASKA
(county where original action was filed)
________________________________,
(name of person listed as plaintiff in original action)
Plaintiff,
Case No. CI _____________
(case number assigned by Clerk of Court)
vs.
CONFIDENTIAL
PARTY INFORMATION
________________________________,
(name of person listed as defendant in original action)
Defendant.
Plaintiff
Name ______________________________________________________________________
(plaintiff’s first, middle and last names)
Address _____________________________________ Phone number _________________
(street, city, state, and ZIP code)
(area code and phone number)
Employer: __________________________________________________________________
(name and address of plaintiff's employer)
Health insurance policy information (if provided through employer)
____________________________________________________________________________
(include name of company, policy number, address to submit claims, and whether insurance is available to minor children)
Defendant
Name ______________________________________________________________________
(defendant’s first, middle and last names)
Address _____________________________________ Phone number _________________
(street, city, state, and ZIP code)
(area code and phone number)
Employer: __________________________________________________________________
(name and address of defendant's employer)
Health insurance policy information (if provided through employer)
______________________________________________
______________________________________________
______________________________________________
______________________________________________
(include name of company, policy number, address to submit claims, and whether
insurance is available to minor children)
Person providing
information:___________________________________
(your first, middle and last names)
Date:________________
Confidential Party Information, DC 6:5(11), PSC Nebraska.