Transcription of Nebraska State Court Form CONFIDENTIAL EMPLOYMENT DC …
1 ( county where original action was filed) _____, (name of person listed as plaintiff in original action) Plaintiff, Case No. _____ (case number assigned by clerk of Court ) vs. CONFIDENTIAL EMPLOYMENT AND HEALTH INSURANCE INFORMATION _____, (name of person listed as defendant in original action) Defendant. Name _____ Plaintiff (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.
2 _____ (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) CONFIDENTIAL EMPLOYMENT AND HEALTH INSURANCE INFORMATIONPage 1 of 1 CONFIDENTIAL EMPLOYMENT and Health Insurance Information DC 6 Rev. 06/19 Date Signature of person providing informationName of person providing informationStreet Box City/ State /ZIP Code Phone Email AddressNebraska State Court Form DC 6 Rev. 06/19 Neb. Rev. Stat. , Neb. Ct. R. 4-215
