Attachment E - STD open and closed paid claim summary.pdf

Claim Gender Status * 200769883 F Closed

200769070 F Closed

200770226 F Closed

200770414 F Closed

200770222 F Closed

200771070 F Closed

200770873 F Closed

200771851 F Closed

200771392 F Closed

200775054 F Closed

200773130 F Closed

200773262 F Closed

200770392 F Closed

200774464 M Closed

200775190 F Closed

200775545 M Closed

200772098 F Closed

01/16/2020 02/18/2020 $2,993.76

Short Term Disability 04/11/1964 10/15/2019 01/06/2020 12/30/2019 $3,554.74

Short Term Disability 06/14/1965 10/14/2019

06/10/2020 12/02/2019 $3,205.72

Short Term Disability 12/07/1991 10/14/2019 11/13/2019 11/13/2019 $359.08

Short Term Disability 12/31/1965 10/02/2019

$15,107.86

Short Term Disability 11/26/1967 10/02/2019 12/12/2019 12/12/2019 $2,090.34

September 2019 Incurred Total:

10/28/2019 10/28/2019 $1,390.04

Short Term Disability 07/11/1953 09/28/2019 10/25/2019 12/23/2019 $4,418.16

Short Term Disability 05/30/1979 09/24/2019

10/11/2019 11/25/2019 $2,511.66

Short Term Disability 03/23/1976 09/20/2019 11/19/2019 11/19/2019 $982.84

Short Term Disability 01/07/1996 09/09/2019

12/23/2019 12/23/2019 $5,188.16

Short Term Disability 09/13/1966 09/07/2019 10/11/2019 10/11/2019 $617.00

Short Term Disability 11/04/1958 09/01/2019

10/11/2019 10/11/2019 $1,044.91

August 2019 Incurred Total: $22,908.43

Short Term Disability 11/05/1966 08/20/2019

01/06/2020 12/30/2019 $6,994.40

Short Term Disability 12/11/1975 08/12/2019 09/13/2019 09/13/2019 $1,107.13

Short Term Disability 05/04/1960 08/08/2019

01/06/2020 11/25/2019 $10,614.62

Short Term Disability 05/25/1960 08/08/2019 09/13/2019 10/02/2019 $3,147.37

Short Term Disability 03/03/1958 08/08/2019

01/15/2020 01/15/2020 $2,491.57

July 2019 Incurred Total: $2,491.57

Short Term Disability 12/12/1977 07/30/2019

STATE OF NEBRASKA Group Effective Date: 07/01/2019

Subgroup: 1002 - STATE OF NEBRASKA

Benefit Date of Birth Incurred Date Initial Payment Date Latest Payment Date Net Benefit Amount

STD STD

FACETS

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

Run Date: 10/28/2024 1:16:25 PM

* Claim Status Descriptions:

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Attachment E

STD STD

FACETS

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

200774363 F Closed

200777176 F Closed

200777141 F Closed

200776430 F Closed

200778759 F Closed

200778936 M Closed

200779473 F Closed

200781299 F Closed

200781482 F Closed

200780567 F Closed

200780458 F Closed

200781254 M Closed

200781256 F Closed

200784710 F Closed

200782412 F Closed

200783855 F Closed

200784642 F Closed

202010934 F Closed

200780880 F Closed

03/11/2021 03/11/2021 $10,340.04

Short Term Disability 11/19/1989 03/14/2020 03/26/2020 03/26/2020 $1,872.80

Short Term Disability 02/28/1959 03/07/2020

$5,626.60

Short Term Disability 11/02/1988 03/06/2020 03/26/2020 03/26/2020 $2,340.31

February 2020 Incurred Total:

03/04/2020 03/04/2020 $2,600.30

Short Term Disability 04/03/1989 02/21/2020 03/25/2020 03/25/2020 $2,302.91

Short Term Disability 04/12/1989 02/19/2020

$12,020.07

Short Term Disability 10/18/1975 02/18/2020 07/02/2020 07/02/2020 $723.39

January 2020 Incurred Total:

02/27/2020 02/27/2020 $2,033.25

Short Term Disability 05/02/1969 01/07/2020 01/29/2020 02/05/2020 $565.59

Short Term Disability 09/26/1978 01/07/2020

$22,648.52

Short Term Disability 06/06/1988 01/06/2020 01/24/2020 03/06/2020 $9,421.23

December 2019 Incurred Total:

02/27/2020 09/01/2020 $7,834.30

Short Term Disability 03/01/1984 12/31/2019 01/29/2020 01/29/2020 $687.16

Short Term Disability 01/03/1967 12/24/2019

01/15/2020 01/15/2020 $1,690.54

Short Term Disability 01/28/1961 12/24/2019 01/28/2020 01/28/2020 $90.47

Short Term Disability 10/15/1961 12/12/2019

01/06/2020 12/30/2019 $7,047.33

Short Term Disability 01/17/1955 12/10/2019 02/13/2020 03/05/2020 $5,298.72

Short Term Disability 02/20/1990 12/10/2019

02/06/2020 12/27/2019 $6,107.41

November 2019 Incurred Total: $6,722.63

Short Term Disability 02/09/1972 11/25/2019

$13,451.28

Short Term Disability 07/21/1995 11/17/2019 01/15/2020 01/15/2020 $615.22

October 2019 Incurred Total:

11/12/2019 11/12/2019 $775.13

Short Term Disability 01/17/1961 10/29/2019 12/19/2019 12/19/2019 $472.51

Short Term Disability 05/08/1974 10/16/2019

Run Date: 10/28/2024 1:16:25 PM

* Claim Status Descriptions:

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

200786843 F Closed

200790978 F Closed

200784909 F Closed

200785910 F Closed

200790370 F Closed

200787370 F Closed

200789864 F Closed

200788209 F Closed

200787892 F Closed

200789337 M Closed

200786436 F Closed

200789931 F Closed

200789627 F Closed

200787363 F Closed

200789531 F Closed

200789503 M Closed

200790208 F Closed

200789712 F Closed

200790330 F Closed

200790040 F Closed

200793561 F Closed

200789133 F Closed

07/20/2020 07/20/2020 $734.11

Short Term Disability 08/12/1987 05/13/2020 07/01/2020 07/01/2020 $4,514.02

Short Term Disability 03/11/1979 05/06/2020

06/18/2020 06/18/2020 $631.36

Short Term Disability 03/22/1984 05/06/2020 06/09/2020 06/26/2020 $2,343.19

Short Term Disability 07/26/1967 05/04/2020

$36,493.58

Short Term Disability 02/13/1978 05/01/2020 06/08/2020 07/02/2020 $3,322.75

April 2020 Incurred Total:

06/17/2020 06/22/2020 $4,779.43

Short Term Disability 07/24/1990 04/30/2020 06/18/2020 06/18/2020 $1,537.96

Short Term Disability 04/26/1961 04/29/2020

06/02/2020 06/02/2020 $2,158.41

Short Term Disability 11/01/1966 04/27/2020 06/08/2020 06/08/2020 $60.40

Short Term Disability 09/03/1986 04/24/2020

06/01/2020 06/01/2020 $2,092.78

Short Term Disability 03/08/1962 04/20/2020 06/24/2020 11/23/2020 $16,730.74

Short Term Disability 06/21/1978 04/08/2020

02/09/2021 02/09/2021 $1,757.32

Short Term Disability 01/20/1991 04/06/2020 05/13/2020 05/13/2020 $3,161.65

Short Term Disability 10/21/1966 04/02/2020

$30,080.30

Short Term Disability 06/14/1987 04/01/2020 06/16/2020 06/16/2020 $4,214.89

March 2020 Incurred Total:

06/18/2020 06/18/2020 $128.57

Short Term Disability 03/07/1968 03/27/2020 02/03/2021 02/03/2021 $691.27

Short Term Disability 07/29/1958 03/24/2020

07/01/2020 07/01/2020 $2,737.30

Short Term Disability 10/27/1980 03/24/2020 05/27/2020 05/27/2020 $4,388.57

Short Term Disability 07/24/1956 03/20/2020

04/22/2020 04/22/2020 $2,672.25

Short Term Disability 08/05/1982 03/18/2020 04/24/2020 04/24/2020 $3,150.14

Short Term Disability 11/07/1988 03/18/2020

06/08/2020 06/08/2020 $1,734.05

Short Term Disability 04/17/1953 03/16/2020 07/14/2020 07/14/2020 $25.00

Short Term Disability 07/02/1961 03/15/2020

Run Date: 10/28/2024 1:16:25 PM

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

202004226 F Closed

200790968 F Closed

200790160 M Closed

200793710 F Closed

202003786 M Closed

200792854 F Closed

200792011 F Closed

202003375 F Closed

200793736 F Closed

200787915 F Closed

202003712 U Closed

200792997 M Closed

200793508 F Closed

202005957 F Closed

200792633 F Closed

202005748 M Closed

202004891 F Closed

200791196 F Closed

202004475 F Closed

202006006 F Closed

202005101 F Closed

09/16/2020 09/16/2020 $2,316.60

Short Term Disability 10/01/1969 08/05/2020 01/20/2021 01/20/2021 $51.09

Short Term Disability 10/29/1990 08/02/2020

11/04/2020 11/04/2020 $230.93

July 2020 Incurred Total: $18,704.63

Short Term Disability 10/10/1963 07/24/2020

08/17/2020 08/17/2020 $2,442.20

Short Term Disability 02/07/1985 07/24/2020 08/03/2020 08/03/2020 $2,766.61

Short Term Disability 03/28/1984 07/21/2020

07/30/2020 10/12/2020 $5,179.68

Short Term Disability 10/24/1981 07/14/2020 12/02/2020 12/02/2020 $2,678.29

Short Term Disability 01/31/1963 07/06/2020

09/01/2020 11/16/2020 $3,787.41

Short Term Disability 08/30/1987 07/03/2020 09/15/2020 09/15/2020 $1,619.51

Short Term Disability 09/13/1966 07/02/2020

09/03/2020 09/03/2020 $3,089.14

June 2020 Incurred Total: $20,950.92

Short Term Disability 12/25/1968 06/25/2020

08/13/2020 08/13/2020 $3,124.80

Short Term Disability 04/05/1971 06/23/2020 08/17/2020 08/20/2020 $2,635.83

Short Term Disability 03/04/1991 06/22/2020

08/13/2020 08/13/2020 $3,585.87

Short Term Disability 09/13/1966 06/19/2020 10/15/2020 10/15/2020 $803.51

Short Term Disability 07/20/1981 06/17/2020

07/30/2020 07/30/2020 $3,944.46

Short Term Disability 04/22/1975 06/16/2020 06/23/2020 07/15/2020 $1,947.15

Short Term Disability 07/16/1988 06/13/2020

$14,891.99

Short Term Disability 08/22/1969 06/02/2020 09/16/2020 09/16/2020 $1,820.16

May 2020 Incurred Total:

06/15/2020 07/02/2020 $2,356.43

Short Term Disability 04/17/1953 05/29/2020 07/14/2020 07/14/2020 $35.72

Short Term Disability 03/07/1986 05/27/2020

08/27/2020 08/27/2020 $834.82

Short Term Disability 03/05/1983 05/17/2020 06/16/2020 06/16/2020 $119.59

Short Term Disability 04/03/1989 05/13/2020

Run Date: 10/28/2024 1:16:25 PM

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

202004244 F Closed

202006226 F Closed

202005660 M Closed

202007528 M Closed

202006920 U Closed

202012401 F Closed

202006898 F Closed

202005968 U Closed

202006739 F Closed

202007562 F Closed

202014936 F Closed

202008466 F Closed

202010484 F Closed

202008624 F Closed

202006575 U Closed

202008060 M Closed

202011386 M Closed

202011024 F Closed

202012388 M Closed

202007370 F Closed

202006408 U Closed

202009828 F Closed

202010859 F Closed

12/01/2020 12/01/2020 $699.05

Short Term Disability 11/18/1965 09/21/2020 10/27/2020 11/17/2020 $3,672.00

Short Term Disability 07/27/1968 09/21/2020

09/25/2020 11/30/2020 $1,320.36

Short Term Disability 03/06/1979 09/17/2020 10/08/2020 10/22/2020 $2,027.57

Short Term Disability 06/25/1969 09/16/2020

01/07/2021 12/31/2020 $13,153.37

Short Term Disability 03/29/1960 09/11/2020 11/30/2020 11/30/2020 $4,374.25

Short Term Disability 04/20/1952 09/09/2020

02/22/2021 02/22/2021 $1,806.86

Short Term Disability 10/16/1968 09/08/2020 11/19/2020 11/19/2020 $3,430.29

Short Term Disability 11/30/1970 09/08/2020

$73,069.28

Short Term Disability 04/09/1991 09/02/2020 10/20/2020 10/20/2020 $3,471.07

August 2020 Incurred Total:

12/01/2020 12/01/2020 $5,261.11

Short Term Disability 03/11/1979 08/31/2020 09/29/2020 09/29/2020 $428.23

Short Term Disability 01/25/1972 08/30/2020

12/22/2020 12/22/2020 $4,039.15

Short Term Disability 03/10/1975 08/30/2020 10/27/2020 10/27/2020 $744.02

Short Term Disability 03/13/1985 08/29/2020

10/05/2020 10/05/2020 $3,563.14

Short Term Disability 01/28/1958 08/28/2020 09/29/2020 11/09/2020 $8,114.60

Short Term Disability 05/13/1985 08/28/2020

01/07/2021 12/07/2020 $10,921.81

Short Term Disability 09/03/1988 08/24/2020 10/05/2020 10/05/2020 $2,930.41

Short Term Disability 09/24/1969 08/18/2020

10/12/2020 11/24/2020 $2,259.30

Short Term Disability 11/28/1961 08/14/2020 12/02/2020 12/02/2020 $2,695.30

Short Term Disability 07/12/1962 08/14/2020

11/16/2020 11/16/2020 $2,367.14

Short Term Disability 07/29/1983 08/11/2020 11/19/2020 12/09/2020 $6,538.27

Short Term Disability 06/22/1982 08/11/2020

09/08/2020 11/02/2020 $8,286.05

Short Term Disability 10/15/1961 08/07/2020 01/06/2021 12/22/2020 $12,553.06

Short Term Disability 12/12/1960 08/07/2020

Run Date: 10/28/2024 1:16:25 PM

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

202009632 F Closed

202015021 F Closed

202011662 F Closed

202010468 F Closed

202014257 F Closed

202004172 F Closed

202012912 F Closed

202008721 U Closed

202112615 F Closed

202012399 F Closed

202012412 F Closed

202013859 F Closed

202013950 F Closed

202013183 F Closed

202016091 F Closed

202017045 F Closed

202014801 F Closed

202017729 F Closed

202105736 M Closed

202100502 F Closed

202018289 F Closed

02/05/2021 05/25/2021 $9,463.11

Short Term Disability 08/05/1975 12/09/2020 02/09/2021 02/09/2021 $345.72

Short Term Disability 04/28/1970 12/07/2020

03/04/2021 03/18/2021 $6,882.25

November 2020 Incurred Total: $27,994.40

Short Term Disability 12/05/1963 11/30/2020

01/19/2021 03/09/2021 $5,093.85

Short Term Disability 12/05/1988 11/26/2020 12/29/2020 12/29/2020 $1,101.16

Short Term Disability 08/25/1966 11/23/2020

01/06/2021 01/15/2021 $3,959.83

Short Term Disability 10/20/1982 11/18/2020 01/22/2021 02/22/2021 $2,156.67

Short Term Disability 08/30/1994 11/15/2020

12/18/2020 12/18/2020 $3,379.35

Short Term Disability 04/02/1989 11/11/2020 01/13/2021 01/13/2021 $1,726.94

Short Term Disability 07/02/1985 11/06/2020

12/01/2020 12/10/2020 $1,565.21

Short Term Disability 10/31/1963 11/03/2020 01/07/2021 01/07/2021 $1,286.06

Short Term Disability 12/26/1983 11/02/2020

$43,702.86

Short Term Disability 05/19/1977 11/02/2020 02/05/2021 12/23/2020 $843.08

October 2020 Incurred Total:

11/06/2020 11/06/2020 $2,189.55

Short Term Disability 10/17/1955 10/30/2020 05/11/2021 05/11/2021 $12,059.04

Short Term Disability 06/12/1980 10/21/2020

11/19/2020 11/19/2020 $3,097.66

Short Term Disability 10/30/1985 10/14/2020 12/04/2020 12/04/2020 $2,634.00

Short Term Disability 05/29/1989 10/13/2020

10/28/2020 10/28/2020 $1,691.76

Short Term Disability 03/01/1958 10/07/2020 01/04/2021 12/28/2020 $9,550.84

Short Term Disability 01/14/1986 10/06/2020

$48,449.49

Short Term Disability 12/20/1993 10/05/2020 01/04/2021 12/28/2020 $12,480.01

September 2020 Incurred Total:

11/09/2020 11/09/2020 $2,037.67

Short Term Disability 07/15/1972 09/28/2020 01/12/2021 04/01/2021 $12,457.00

Short Term Disability 04/28/1997 09/28/2020

Run Date: 10/28/2024 1:16:25 PM

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

202102171 M Closed

202100703 F Closed

202016889 F Closed

202101800 U Closed

202017482 F Closed

202102332 M Closed

202100269 M Closed

202101440 M Closed

202100492 M Closed

202101267 F Closed

202015981 F Closed

202105552 F Closed

202103801 F Closed

202101884 F Closed

202105560 F Closed

202107996 F Closed

202105783 M Closed

202104351 F Closed

202105161 F Closed

202105194 M Closed

202112075 F Closed

$31,943.52

Short Term Disability 10/26/1969 03/03/2021 04/13/2021 05/28/2021 $2,047.89

February 2021 Incurred Total:

04/13/2021 04/13/2021 $2,742.98

Short Term Disability 10/25/1974 02/25/2021 03/23/2021 06/28/2021 $4,461.81

Short Term Disability 01/08/1982 02/18/2021

05/19/2021 05/19/2021 $3,966.19

Short Term Disability 02/16/1995 02/17/2021 03/30/2021 03/30/2021 $3,108.70

Short Term Disability 07/12/1961 02/14/2021

03/15/2021 08/20/2021 $9,483.50

Short Term Disability 09/02/1999 02/08/2021 05/06/2021 05/06/2021 $4,423.92

Short Term Disability 03/21/1968 02/01/2021

$14,361.61

Short Term Disability 08/17/1962 02/01/2021 02/15/2021 04/08/2021 $3,756.42

January 2021 Incurred Total:

03/18/2021 06/25/2021 $5,061.11

Short Term Disability 10/12/1973 01/25/2021 02/15/2021 02/15/2021 $1,234.29

Short Term Disability 12/14/1958 01/21/2021

03/02/2021 03/02/2021 $263.35

Short Term Disability 07/05/1994 01/20/2021 03/01/2021 03/01/2021 $1,846.12

Short Term Disability 08/17/1996 01/14/2021

03/12/2021 03/12/2021 $2,265.50

Short Term Disability 07/29/1964 01/13/2021 02/15/2021 04/08/2021 $3,279.81

Short Term Disability 11/11/1966 01/11/2021

$30,306.55

Short Term Disability 10/09/1997 01/03/2021 02/15/2021 03/02/2021 $411.43

December 2020 Incurred Total:

01/19/2021 03/24/2021 $4,531.55

Short Term Disability 04/26/1961 12/30/2020 04/22/2021 04/22/2021 $1,342.17

Short Term Disability 09/12/1964 12/29/2020

02/05/2021 04/23/2021 $1,066.34

Short Term Disability 06/12/1980 12/28/2020 02/05/2021 05/04/2021 $5,441.69

Short Term Disability 09/25/1996 12/26/2020

04/13/2021 04/13/2021 $1,657.34

Short Term Disability 07/31/1956 12/21/2020 03/18/2021 03/18/2021 $6,458.63

Short Term Disability 06/14/1965 12/13/2020

Run Date: 10/28/2024 1:16:25 PM

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

202117101 F Closed

202107617 F Closed

202113116 M Closed

202127929 M Closed

202112413 M Closed

202141252 F Closed

202113481 F Closed

202128015 F Closed

202115900 F Closed

202116864 F Closed

202118471 M Closed

202115705 M Closed

202111505 F Closed

202113381 F Closed

202116931 F Closed

202123151 F Closed

202119039 M Closed

202116320 F Closed

202125299 F Closed

202118234 F Closed

202124876 M Closed

202121775 F Closed

03/23/2022 12/20/2021 $10,089.93

Short Term Disability 10/23/1987 05/19/2021 06/23/2021 06/23/2021 $868.46

Short Term Disability 11/20/1969 05/18/2021

07/01/2021 07/01/2021 $3,240.00

Short Term Disability 06/06/1987 05/18/2021 06/04/2021 06/04/2021 $125.00

Short Term Disability 02/06/1972 05/14/2021

06/08/2021 06/08/2021 $432.00

Short Term Disability 11/01/1966 05/13/2021 06/04/2021 06/04/2021 $130.71

Short Term Disability 04/25/1984 05/12/2021

$29,121.70

Short Term Disability 10/07/1981 05/06/2021 06/28/2021 06/28/2021 $1,785.39

April 2021 Incurred Total:

05/21/2021 05/21/2021 $894.71

Short Term Disability 07/26/1967 04/30/2021 05/24/2021 06/07/2021 $2,232.00

Short Term Disability 08/06/1989 04/24/2021

05/20/2021 06/01/2021 $1,367.44

Short Term Disability 03/15/1995 04/23/2021 06/04/2021 06/04/2021 $2,840.87

Short Term Disability 03/03/1972 04/22/2021

05/20/2021 05/20/2021 $760.36

Short Term Disability 12/16/1972 04/11/2021 06/25/2021 08/04/2021 $1,950.49

Short Term Disability 09/13/1966 04/09/2021

08/09/2021 11/03/2021 $11,218.64

Short Term Disability 03/05/1983 04/07/2021 05/06/2021 05/06/2021 $2,018.47

Short Term Disability 06/22/1979 04/05/2021

$30,583.14

Short Term Disability 02/13/1978 04/03/2021 04/23/2021 07/13/2021 $5,838.72

March 2021 Incurred Total:

06/01/2021 09/24/2021 $8,749.10

Short Term Disability 09/06/1951 03/24/2021 03/29/2022 10/28/2021 $2,189.67

Short Term Disability 01/13/1963 03/23/2021

08/06/2021 09/22/2021 $442.86

Short Term Disability 12/30/1964 03/22/2021 09/21/2021 09/21/2021 $3,692.88

Short Term Disability 08/10/1992 03/18/2021

05/05/2022 08/04/2021 $11,348.40

Short Term Disability 03/23/1976 03/07/2021 05/06/2021 06/02/2021 $2,112.34

Short Term Disability 09/07/1972 03/05/2021

Run Date: 10/28/2024 1:16:25 PM

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

202124926 F Closed

202129706 F Closed

202120364 F Closed

202124553 F Closed

202121975 M Closed

202124614 F Closed

202125564 F Closed

202126086 F Closed

202120353 M Closed

202125379 F Closed

202124880 F Closed

202124687 F Closed

202118607 F Closed

202134017 F Closed

202124718 M Closed

202127765 F Closed

202127835 M Closed

202127687 F Closed

202123189 F Closed

202131838 F Closed

202132507 F Closed

202128910 F Closed

10/01/2021 10/08/2021 $2,113.90

Short Term Disability 11/10/1994 07/07/2021 08/27/2021 08/27/2021 $1,121.81

Short Term Disability 12/05/1988 07/06/2021

09/29/2021 10/11/2021 $1,992.93

June 2021 Incurred Total: $34,138.45

Short Term Disability 11/05/1968 06/29/2021

07/09/2021 08/26/2021 $3,537.69

Short Term Disability 01/17/1986 06/28/2021 08/19/2021 08/19/2021 $2,549.32

Short Term Disability 05/31/1959 06/24/2021

08/06/2021 08/06/2021 $1,491.48

Short Term Disability 06/14/1965 06/23/2021 08/25/2021 08/25/2021 $579.02

Short Term Disability 01/09/1976 06/21/2021

10/13/2021 10/29/2021 $2,064.52

Short Term Disability 07/11/1959 06/21/2021 03/23/2022 08/12/2021 $3,280.11

Short Term Disability 07/06/1964 06/14/2021

06/25/2021 08/24/2021 $6,157.94

Short Term Disability 09/06/1964 06/08/2021 02/14/2022 10/04/2022 $2,067.88

Short Term Disability 04/08/1960 06/04/2021

07/12/2021 08/06/2021 $4,478.85

Short Term Disability 01/09/1986 06/03/2021 06/28/2021 06/28/2021 $3,363.57

Short Term Disability 07/15/1997 06/01/2021

$39,007.73

Short Term Disability 03/04/1969 06/01/2021 06/14/2021 08/30/2021 $2,575.14

May 2021 Incurred Total:

07/13/2021 08/09/2021 $4,309.92

Short Term Disability 01/08/1982 05/26/2021 08/09/2021 08/17/2021 $4,573.48

Short Term Disability 05/03/1989 05/25/2021

06/14/2021 06/14/2021 $1,282.29

Short Term Disability 07/25/1976 05/24/2021 06/18/2021 06/18/2021 $1,206.14

Short Term Disability 06/28/1969 05/24/2021

06/04/2021 07/15/2021 $3,818.50

Short Term Disability 04/10/1996 05/23/2021 06/16/2021 06/16/2021 $2,921.66

Short Term Disability 09/27/1978 05/21/2021

07/20/2021 08/23/2021 $1,667.19

Short Term Disability 11/01/1989 05/20/2021 08/17/2021 08/17/2021 $2,557.06

Short Term Disability 01/05/1991 05/19/2021

Run Date: 10/28/2024 1:16:25 PM

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

202132403 F Closed

202132792 F Closed

202132198 F Closed

202128643 M Closed

202139854 F Closed

202132634 F Closed

202142219 F Closed

202129667 F Closed

202141627 F Closed

202138574 F Closed

202141363 M Closed

202145994 F Closed

202143292 F Closed

202133696 F Closed

202132448 F Closed

202143354 F Closed

202142237 F Closed

202150810 F Closed

202147779 F Closed

202145111 F Closed

202144877 F Closed

202147297 M Closed

10/22/2021 10/22/2021 $413.03

Short Term Disability 06/24/1973 09/27/2021 11/17/2021 12/09/2021 $1,610.88

Short Term Disability 11/25/1959 09/24/2021

12/02/2021 12/02/2021 $178.57

Short Term Disability 06/12/1965 09/16/2021 10/14/2021 10/14/2021 $1,566.86

Short Term Disability 06/22/1988 09/15/2021

10/14/2021 10/14/2021 $3,098.41

Short Term Disability 09/25/1971 09/12/2021 12/02/2021 12/02/2021 $4,156.75

Short Term Disability 10/28/1992 09/10/2021

09/29/2021 09/29/2021 $2,134.50

Short Term Disability 09/10/1981 09/09/2021 10/13/2021 10/13/2021 $315.62

Short Term Disability 05/19/1977 09/08/2021

$19,131.77

Short Term Disability 08/05/1982 09/05/2021 10/21/2021 10/21/2021 $2,663.31

August 2021 Incurred Total:

12/02/2021 12/10/2021 $0.00

Short Term Disability 12/27/1989 08/26/2021 12/02/2021 12/02/2021 $2,957.63

Short Term Disability 11/05/1975 08/22/2021

09/15/2021 09/15/2021 $1,987.54

Short Term Disability 07/11/1966 08/18/2021 01/06/2022 12/30/2021 $9,859.28

Short Term Disability 01/25/1974 08/10/2021

08/30/2021 08/30/2021 $1,117.29

Short Term Disability 11/10/1953 08/09/2021 10/13/2021 10/28/2021 $2,279.91

Short Term Disability 08/24/1954 08/03/2021

$25,241.19

Short Term Disability 07/06/1966 08/02/2021 09/27/2021 09/27/2021 $930.12

July 2021 Incurred Total:

09/08/2021 09/08/2021 $1,938.04

Short Term Disability 09/22/1986 07/30/2021 08/31/2021 08/31/2021 $4,805.64

Short Term Disability 03/09/1981 07/29/2021

08/02/2021 08/26/2021 $2,496.32

Short Term Disability 06/28/1969 07/26/2021 08/17/2021 11/08/2021 $7,618.29

Short Term Disability 09/27/1978 07/22/2021

09/08/2021 09/08/2021 $2,364.71

Short Term Disability 10/26/1979 07/14/2021 09/29/2021 09/29/2021 $2,782.48

Short Term Disability 11/01/1969 07/12/2021

Run Date: 10/28/2024 1:16:25 PM

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

202152608 M Closed

202153158 F Closed

202143309 F Closed

202147620 M Closed

202145040 F Closed

202147476 F Closed

202214433 F Closed

202191039 M Closed

202143674 F Closed

202186194 F Closed

202148421 F Closed

202148914 F Closed

202150976 F Closed

202187177 F Closed

202183506 M Closed

202186971 F Closed

202147389 F Closed

202184203 F Closed

202185936 F Closed

202184428 M Closed

202215766 M Closed

202146697 F Closed

03/04/2022 03/04/2022 $371.43

Short Term Disability 02/28/1995 11/17/2021 12/08/2021 12/08/2021 $1,445.52

Short Term Disability 08/07/1957 11/16/2021

01/21/2022 12/30/2021 $5,398.94

Short Term Disability 07/12/1961 11/16/2021 01/04/2022 02/04/2022 $8,253.96

Short Term Disability 03/16/1983 11/15/2021

12/14/2021 12/14/2021 $2,270.40

Short Term Disability 02/06/1972 11/10/2021 01/03/2022 12/27/2021 $11,075.57

Short Term Disability 08/28/1993 11/08/2021

$35,757.07

Short Term Disability 08/17/1984 11/07/2021 01/11/2022 03/08/2022 $5,039.45

October 2021 Incurred Total:

03/01/2022 03/01/2022 $272.99

Short Term Disability 12/09/1962 10/28/2021 04/28/2022 05/11/2022 $1,529.03

Short Term Disability 09/29/1985 10/25/2021

03/04/2022 12/06/2021 $3,277.46

Short Term Disability 02/13/1978 10/25/2021 11/18/2021 12/01/2021 $1,824.90

Short Term Disability 12/14/1958 10/25/2021

12/13/2021 12/13/2021 $1,331.73

Short Term Disability 09/14/1978 10/19/2021 01/03/2022 12/27/2021 $4,825.92

Short Term Disability 11/02/1988 10/17/2021

03/09/2022 03/30/2022 $4,907.97

Short Term Disability 12/27/1989 10/14/2021 11/22/2021 11/22/2021 $1,712.78

Short Term Disability 12/05/1961 10/13/2021

03/29/2022 12/27/2021 $5,084.82

Short Term Disability 09/25/1960 10/12/2021 02/23/2022 03/08/2022 $2,539.34

Short Term Disability 10/31/1963 10/08/2021

11/09/2021 11/09/2021 $1,142.28

Short Term Disability 12/10/1972 10/04/2021 05/26/2022 12/20/2021 $3,522.13

Short Term Disability 06/20/1985 10/01/2021

$19,047.17

Short Term Disability 09/20/1991 10/01/2021 10/19/2021 11/29/2021 $3,785.72

September 2021 Incurred Total:

12/13/2021 12/13/2021 $357.14

Short Term Disability 12/11/1975 09/28/2021 12/15/2021 12/15/2021 $2,552.10

Short Term Disability 11/09/1954 09/27/2021

Run Date: 10/28/2024 1:16:25 PM

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

202184596 F Closed

202151174 M Closed

202186298 F Closed

202234597 M Closed

202184209 F Closed

202185662 F Closed

202191247 F Closed

202192102 M Closed

202191364 F Closed

202216558 M Closed

202209332 F Closed

202210300 F Closed

202215210 M Closed

202291839 M Closed

202191991 F Closed

202213025 M Closed

202226753 M Closed

202210520 F Closed

202215179 M Closed

202214814 F Closed

202214349 F Closed

202223889 M Closed

03/01/2022 03/01/2022 $366.89

Short Term Disability 07/25/1992 01/24/2022 03/28/2022 03/28/2022 $472.85

Short Term Disability 07/25/1976 01/24/2022

03/01/2022 03/01/2022 $123.99

Short Term Disability 02/01/1983 01/18/2022 02/18/2022 03/08/2022 $1,886.48

Short Term Disability 11/27/1982 01/16/2022

03/31/2022 09/20/2022 $12,921.42

Short Term Disability 05/31/1959 01/13/2022 01/28/2022 04/05/2022 $4,369.17

Short Term Disability 09/08/1965 01/10/2022

03/01/2022 03/01/2022 $799.57

Short Term Disability 07/11/1991 01/10/2022 03/01/2022 03/01/2022 $182.32

Short Term Disability 05/12/1994 01/10/2022

03/01/2022 03/01/2022 $2,883.43

Short Term Disability 05/03/1965 01/07/2022 06/28/2023 06/28/2023 $15,965.36

Short Term Disability 09/11/1988 01/05/2022

03/01/2022 03/01/2022 $125.00

December 2021 Incurred Total: $15,640.71

Short Term Disability 04/10/1986 12/18/2021

02/22/2022 03/28/2022 $6,700.82

Short Term Disability 10/28/1987 12/18/2021 01/26/2022 01/26/2022 $2,468.57

Short Term Disability 02/22/1970 12/16/2021

02/08/2022 03/08/2022 $993.26

Short Term Disability 10/28/1992 12/10/2021 01/10/2022 01/10/2022 $3,764.02

Short Term Disability 10/17/1975 12/02/2021

01/31/2022 01/31/2022 $1,175.71

Short Term Disability 07/31/1968 12/01/2021 03/01/2022 03/01/2022 $413.33

Short Term Disability 12/22/1989 12/01/2021

12/15/2021 12/15/2021 $4,061.50

November 2021 Incurred Total: $59,386.31

Short Term Disability 03/20/1995 11/30/2021

02/02/2022 02/02/2022 $1,044.61

Short Term Disability 11/02/1974 11/24/2021 04/18/2022 04/18/2022 $794.79

Short Term Disability 04/23/1970 11/19/2021

01/06/2022 12/30/2021 $8,038.11

Short Term Disability 04/28/1976 11/18/2021 01/03/2022 12/27/2021 $11,592.03

Short Term Disability 04/20/1952 11/17/2021

Run Date: 10/28/2024 1:16:25 PM

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

202215564 F Closed

202240167 F Closed

202224248 F Closed

202234734 M Closed

202275917 M Closed

202224003 M Closed

202226923 F Closed

202240993 M Closed

202223592 F Closed

202224561 F Closed

202237326 F Closed

202212983 F Closed

202210319 F Closed

202239783 F Closed

202240894 M Closed

202302088 M Closed

202187054 F Closed

202239675 M Closed

202247287 F Closed

202254031 F Closed

202244679 F Closed

$30,662.67

Short Term Disability 10/13/1996 04/03/2022 04/21/2022 04/21/2022 $2,838.86

March 2022 Incurred Total:

04/21/2022 04/21/2022 $3,071.04

Short Term Disability 08/26/1980 03/31/2022 05/25/2022 06/09/2022 $1,709.00

Short Term Disability 10/03/1995 03/30/2022

05/05/2022 05/05/2022 $1,642.06

Short Term Disability 10/16/1968 03/29/2022 04/11/2022 08/25/2022 $9,442.52

Short Term Disability 05/05/1993 03/25/2022

04/18/2022 04/18/2022 $1,626.57

Short Term Disability 12/30/1964 03/18/2022 07/29/2022 07/29/2022 $7,755.43

Short Term Disability 01/16/1992 03/07/2022

04/15/2022 04/15/2022 $3,222.45

Short Term Disability 08/30/1991 03/07/2022 04/12/2022 04/12/2022 $2,193.60

Short Term Disability 01/20/1991 03/04/2022

04/29/2022 04/29/2022 $1,408.07

February 2022 Incurred Total: $40,261.84

Short Term Disability 04/06/1966 02/28/2022

04/14/2022 06/20/2022 $12,588.72

Short Term Disability 01/21/1969 02/26/2022 04/15/2022 05/23/2022 $5,083.65

Short Term Disability 10/06/1961 02/23/2022

06/09/2022 06/09/2022 $3,008.57

Short Term Disability 08/12/1997 02/17/2022 04/18/2022 04/18/2022 $125.00

Short Term Disability 10/19/1975 02/08/2022

03/07/2022 04/07/2022 $3,342.59

Short Term Disability 12/14/1958 02/08/2022 03/11/2022 04/28/2022 $590.21

Short Term Disability 06/28/1961 02/08/2022

04/26/2022 05/02/2022 $7,379.15

Short Term Disability 11/02/1974 02/07/2022 04/18/2022 05/10/2022 $5,550.89

Short Term Disability 05/26/1993 02/07/2022

04/18/2022 04/18/2022 $767.56

Short Term Disability 10/23/1995 02/07/2022 03/24/2022 03/24/2022 $417.43

Short Term Disability 08/03/1981 02/03/2022

02/18/2022 07/07/2022 $4,698.96

January 2022 Incurred Total: $44,670.44

Short Term Disability 05/25/1960 01/31/2022

Run Date: 10/28/2024 1:16:25 PM

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

202247269 M Closed

202245494 F Closed

202292359 M Closed

202275856 F Closed

202292731 M Closed

202253631 F Closed

202336569 F Closed

202336552 F Closed

202336936 M Closed

202292489 F Closed

202336695 F Closed

202391538 F Closed

202301554 F Closed

202331638 F Closed

202336297 F Closed

202392195 M Closed

202337035 F Closed

202335827 F Closed

202336878 F Closed

202336645 F Closed

202384592 F Closed

202325407 F Closed

08/30/2022 08/30/2022 $125.00

Short Term Disability 10/17/1992 06/17/2022 07/12/2022 07/12/2022 $1,789.15

Short Term Disability 03/07/1991 06/14/2022

07/12/2022 12/19/2022 $11,406.72

Short Term Disability 11/26/1957 06/08/2022 09/02/2022 09/02/2022 $2,924.27

Short Term Disability 02/22/1983 06/03/2022

$50,219.26

Short Term Disability 05/31/1959 06/01/2022 07/13/2022 07/13/2022 $708.51

May 2022 Incurred Total:

08/24/2022 09/29/2022 $4,298.10

Short Term Disability 06/22/1968 05/31/2022 09/19/2022 09/19/2022 $3,393.30

Short Term Disability 06/25/1967 05/25/2022

07/12/2022 08/18/2022 $8,064.00

Short Term Disability 11/06/1964 05/23/2022 07/20/2022 08/24/2022 $6,635.68

Short Term Disability 12/22/1989 05/23/2022

09/16/2022 12/15/2022 $12,411.36

Short Term Disability 09/28/1996 05/19/2022 07/06/2022 07/06/2022 $3,011.00

Short Term Disability 09/07/1972 05/18/2022

10/03/2022 10/03/2022 $2,791.88

Short Term Disability 07/24/1990 05/18/2022 08/11/2022 08/11/2022 $2,840.95

Short Term Disability 07/03/1989 05/16/2022

07/01/2022 07/01/2022 $2,763.21

Short Term Disability 12/15/1960 05/13/2022 07/05/2022 07/19/2022 $4,009.78

Short Term Disability 06/12/1984 05/13/2022

08/22/2022 08/22/2022 $360.05

April 2022 Incurred Total: $28,976.40

Short Term Disability 05/12/1994 04/30/2022

06/02/2022 11/05/2022 $8,307.43

Short Term Disability 03/14/1960 04/29/2022 05/23/2022 10/03/2022 $12,793.12

Short Term Disability 04/21/1969 04/26/2022

05/31/2022 06/02/2022 $757.62

Short Term Disability 11/27/1966 04/25/2022 10/06/2022 10/06/2022 $75.00

Short Term Disability 01/09/1989 04/19/2022

05/23/2022 05/27/2022 $1,620.15

Short Term Disability 06/17/1984 04/15/2022 06/02/2022 06/02/2022 $2,224.17

Short Term Disability 07/29/1964 04/04/2022

Run Date: 10/28/2024 1:16:25 PM

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

202433605 F Closed

202376207 F Closed

202345865 M Closed

202403473 F Closed

202407292 M Closed

202346337 F Closed

202421242 F Closed

202421681 M Closed

202403378 M Closed

202336383 M Closed

202378291 F Closed

202390487 F Closed

202337432 F Closed

202389876 F Closed

202336414 F Closed

202401608 F Closed

202419290 F Closed

202391335 F Closed

202407222 F Closed

202410775 M Closed

202472839 F Closed

202419489 M Closed

01/03/2023 12/29/2022 $13,138.60

Short Term Disability 10/22/1967 08/12/2022 02/02/2023 12/29/2022 $9,389.50

Short Term Disability 09/16/1982 08/06/2022

10/04/2022 10/05/2022 $2,876.72

Short Term Disability 04/30/1992 08/03/2022 12/01/2022 12/01/2022 $7.14

Short Term Disability 11/09/1963 08/01/2022

09/06/2022 09/06/2022 $3,071.04

July 2022 Incurred Total: $45,268.03

Short Term Disability 10/02/1980 07/27/2022

01/06/2023 12/30/2022 $17,472.00

Short Term Disability 09/18/1976 07/26/2022 10/21/2022 10/21/2022 $1,992.39

Short Term Disability 07/30/1970 07/26/2022

09/08/2022 12/30/2022 $11,635.00

Short Term Disability 11/22/1981 07/26/2022 08/16/2022 09/01/2022 $3,656.85

Short Term Disability 05/11/1984 07/20/2022

01/30/2023 01/30/2023 $3,110.40

Short Term Disability 04/30/1993 07/18/2022 11/08/2022 11/08/2022 $175.00

Short Term Disability 05/22/1981 07/11/2022

08/10/2022 09/19/2022 $1,576.30

Short Term Disability 09/14/1992 07/02/2022 08/08/2022 08/08/2022 $2,579.05

Short Term Disability 10/21/1954 07/01/2022

08/18/2022 08/18/2022 $3,018.86

June 2022 Incurred Total: $55,146.17

Short Term Disability 01/09/1966 06/29/2022

10/20/2022 10/20/2022 $3,966.28

Short Term Disability 01/06/1988 06/27/2022 01/23/2023 12/13/2022 $11,329.20

Short Term Disability 03/09/1981 06/27/2022

10/24/2022 10/24/2022 $7,006.74

Short Term Disability 05/26/1962 06/27/2022 07/27/2022 08/29/2022 $2,980.53

Short Term Disability 04/12/1968 06/25/2022

07/19/2022 10/05/2022 $6,558.79

Short Term Disability 05/20/1988 06/24/2022 09/02/2022 09/02/2022 $864.42

Short Term Disability 01/16/1968 06/23/2022

10/17/2022 10/17/2022 $1,830.65

Short Term Disability 07/05/1994 06/21/2022 07/25/2022 07/25/2022 $637.05

Short Term Disability 11/27/1966 06/17/2022

Run Date: 10/28/2024 1:16:25 PM

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

202345879 F Closed

202410337 F Closed

202392261 F Closed

202416948 F Closed

202411009 F Closed

202407338 F Closed

202416389 M Closed

202420145 F Closed

202421624 F Closed

202422327 F Closed

202420153 F Closed

202422393 M Closed

202432952 M Closed

202422662 M Closed

202443764 M Closed

202410624 M Closed

202489217 F Closed

202477029 F Closed

202422754 F Closed

202473400 M Closed

202423101 F Closed

202419512 F Closed

02/03/2023 12/16/2022 $930.36

Short Term Disability 02/04/1965 10/13/2022 11/15/2022 12/21/2022 $1,604.37

Short Term Disability 07/30/1965 10/10/2022

$49,607.60

Short Term Disability 09/03/1972 10/08/2022 01/30/2023 01/30/2023 $434.74

September 2022 Incurred Total:

01/06/2023 01/06/2023 $687.65

Short Term Disability 12/06/1965 09/30/2022 01/06/2023 12/28/2022 $6,441.43

Short Term Disability 01/17/1992 09/29/2022

11/23/2022 11/23/2022 $4,608.00

Short Term Disability 09/08/1960 09/28/2022 01/05/2023 07/10/2023 $8,165.37

Short Term Disability 03/04/1975 09/28/2022

01/04/2023 12/28/2022 $8,813.67

Short Term Disability 09/08/1967 09/27/2022 05/19/2023 12/09/2022 $5,657.14

Short Term Disability 09/30/1984 09/27/2022

02/22/2023 12/12/2022 $4,806.29

Short Term Disability 11/05/1962 09/20/2022 11/23/2022 11/23/2022 $3,227.92

Short Term Disability 04/26/1956 09/16/2022

10/06/2022 10/06/2022 $1,312.66

Short Term Disability 09/25/1975 09/14/2022 11/16/2022 11/16/2022 $2,126.30

Short Term Disability 02/04/1965 09/10/2022

10/26/2022 10/26/2022 $571.19

Short Term Disability 06/14/1979 09/09/2022 10/20/2022 10/20/2022 $1,016.23

Short Term Disability 02/15/1986 09/09/2022

$44,337.72

Short Term Disability 10/17/1975 09/01/2022 09/26/2022 11/23/2022 $2,173.75

August 2022 Incurred Total:

10/31/2022 10/31/2022 $2,976.00

Short Term Disability 04/02/1989 08/27/2022 09/28/2022 09/28/2022 $1,108.61

Short Term Disability 11/22/1993 08/25/2022

08/31/2022 11/23/2022 $4,801.85

Short Term Disability 01/01/1974 08/24/2022 10/07/2022 10/07/2022 $4,906.80

Short Term Disability 03/06/1993 08/20/2022

09/06/2022 09/06/2022 $2,273.14

Short Term Disability 02/13/1991 08/16/2022 08/31/2022 08/31/2022 $2,859.36

Short Term Disability 08/01/1994 08/13/2022

Run Date: 10/28/2024 1:16:25 PM

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

202421836 M Closed

202472977 F Closed

202472744 F Closed

202509290 M Closed

202473451 F Closed

202485530 M Closed

202498281 F Closed

202451059 F Closed

202523632 F Closed

202501677 F Closed

202516353 F Closed

202483096 F Closed

202509216 F Closed

202502112 F Closed

202537706 F Closed

202523700 F Closed

202838159 F Closed

202570053 F Closed

202493709 F Closed

202537494 M Closed

202523385 F Closed

202590573 F Closed

01/09/2023 01/09/2023 $5,207.05

Short Term Disability 09/29/1985 12/14/2022 09/07/2023 09/07/2023 $1,668.80

Short Term Disability 10/03/1970 12/13/2022

03/27/2023 03/27/2023 $175.00

Short Term Disability 04/03/1977 12/09/2022 02/02/2023 05/25/2023 $8,991.42

Short Term Disability 11/07/1985 12/09/2022

02/09/2024 11/08/2023 $5,609.64

Short Term Disability 09/02/1964 12/08/2022 03/24/2023 03/29/2023 $3,942.62

Short Term Disability 01/03/1965 12/07/2022

$39,050.68

Short Term Disability 01/03/1982 12/03/2022 01/26/2023 01/26/2023 $733.10

November 2022 Incurred Total:

01/05/2023 12/29/2022 $9,144.74

Short Term Disability 12/11/1979 11/29/2022 03/28/2023 06/02/2023 $17,126.69

Short Term Disability 09/22/1972 11/28/2022

01/05/2023 01/09/2023 $1,192.52

Short Term Disability 10/08/1992 11/24/2022 01/27/2023 01/27/2023 $1,832.29

Short Term Disability 11/28/1967 11/23/2022

01/11/2023 01/11/2023 $2,885.19

Short Term Disability 11/10/1994 11/21/2022 01/23/2023 01/23/2023 $2,715.97

Short Term Disability 06/20/1966 11/17/2022

01/26/2023 01/26/2023 $128.57

Short Term Disability 07/25/1976 11/14/2022 04/24/2023 04/24/2023 $4,024.71

Short Term Disability 02/28/1998 11/11/2022

01/13/2023 04/26/2023 $6,241.65

October 2022 Incurred Total: $44,503.62

Short Term Disability 05/12/1968 10/28/2022

11/16/2022 11/16/2022 $2,975.46

Short Term Disability 12/27/1963 10/28/2022 01/12/2023 01/12/2023 $2,228.54

Short Term Disability 10/03/1970 10/26/2022

11/15/2022 11/15/2022 $5,348.57

Short Term Disability 12/30/1964 10/23/2022 05/08/2023 09/06/2023 $16,395.57

Short Term Disability 06/16/1997 10/22/2022

01/02/2023 12/28/2022 $4,587.86

Short Term Disability 12/12/1960 10/14/2022 12/20/2022 12/20/2022 $3,756.50

Short Term Disability 05/31/1967 10/14/2022

Run Date: 10/28/2024 1:16:25 PM

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

202433185 F Closed

202555344 F Closed

202581731 F Closed

202571254 M Closed

202537702 F Closed

202568990 M Closed

202702009 F Closed

202553012 F Closed

202544958 F Closed

202553201 F Closed

202570058 F Closed

202605562 F Closed

202582135 F Closed

202572845 F Closed

202689680 F Closed

202544963 F Closed

202561396 F Closed

202561445 F Closed

202628306 F Closed

202609398 F Closed

202584212 F Closed

202637716 F Closed

05/01/2023 05/01/2023 $332.28

Short Term Disability 03/23/1976 02/25/2023 07/18/2023 07/18/2023 $2,440.89

Short Term Disability 11/07/1989 02/25/2023

03/28/2023 03/28/2023 $980.57

Short Term Disability 06/06/1988 02/24/2023 05/10/2023 05/16/2023 $1,580.54

Short Term Disability 08/12/1975 02/23/2023

04/10/2023 04/10/2023 $1,139.25

Short Term Disability 08/05/1982 02/22/2023 03/29/2023 03/29/2023 $3,376.00

Short Term Disability 06/14/1979 02/16/2023

05/25/2023 05/25/2023 $3,648.00

Short Term Disability 09/20/1991 02/16/2023 04/12/2023 05/17/2023 $616.27

Short Term Disability 02/06/1995 02/14/2023

04/26/2023 04/26/2023 $4,432.49

Short Term Disability 04/22/1980 02/13/2023 03/09/2023 05/03/2023 $7,556.57

Short Term Disability 03/28/1984 02/10/2023

03/20/2023 04/05/2023 $5,301.32

Short Term Disability 10/08/1981 02/09/2023 03/28/2023 05/18/2023 $4,259.28

Short Term Disability 03/26/1969 02/02/2023

04/11/2023 04/11/2023 $89.29

January 2023 Incurred Total: $33,265.20

Short Term Disability 08/12/1985 01/31/2023

02/15/2023 05/30/2023 $5,234.48

Short Term Disability 02/16/1995 01/27/2023 03/20/2023 03/20/2023 $3,593.79

Short Term Disability 05/29/1971 01/26/2023

04/24/2023 04/24/2023 $96.19

Short Term Disability 10/11/1961 01/25/2023 06/27/2023 07/20/2023 $6,732.18

Short Term Disability 03/04/1969 01/25/2023

01/16/2024 11/22/2023 $4,980.92

Short Term Disability 11/07/1988 01/24/2023 04/18/2023 04/18/2023 $1,816.94

Short Term Disability 03/03/1998 01/21/2023

$31,090.48

Short Term Disability 09/24/1980 01/13/2023 03/22/2023 05/04/2023 $10,721.41

December 2022 Incurred Total:

02/01/2023 02/01/2023 $2,213.43

Short Term Disability 12/10/1999 12/15/2022 04/03/2023 04/03/2023 $2,549.42

Short Term Disability 01/07/1989 12/15/2022

Run Date: 10/28/2024 1:16:25 PM

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

202617665 F Closed

202617592 F Closed

202701885 M Closed

202637949 F Closed

202625165 F Closed

202581392 M Closed

202638465 F Closed

202628315 M Closed

202638611 F Closed

202639029 F Closed

202638748 F Closed

202618788 F Closed

202627563 M Closed

202638749 F Closed

202652782 F Closed

202676368 F Closed

202659760 M Closed

202624523 F Closed

202627451 F Closed

202630363 F Closed

202722948 F Closed

202617701 F Closed

06/06/2023 06/13/2023 $2,604.93

Short Term Disability 12/24/1989 04/07/2023 04/24/2023 04/24/2023 $2,381.35

Short Term Disability 06/20/1966 04/06/2023

05/10/2023 05/22/2023 $4,032.00

Short Term Disability 09/23/1968 04/06/2023 04/19/2023 06/05/2023 $4,208.63

Short Term Disability 04/05/1978 04/05/2023

07/17/2023 07/17/2023 $2,103.07

Short Term Disability 07/07/1958 04/04/2023 05/10/2023 07/11/2023 $4,534.43

Short Term Disability 02/20/1997 04/01/2023

05/08/2023 06/05/2023 $9,221.42

March 2023 Incurred Total: $97,047.48

Short Term Disability 11/10/1961 03/30/2023

05/26/2023 11/01/2023 $10,561.19

Short Term Disability 07/13/1990 03/30/2023 04/28/2023 04/28/2023 $2,588.78

Short Term Disability 11/29/1962 03/30/2023

04/25/2023 05/15/2023 $426.80

Short Term Disability 12/04/1973 03/30/2023 04/24/2023 08/29/2023 $12,488.45

Short Term Disability 04/13/1975 03/29/2023

06/28/2023 07/17/2023 $8,728.77

Short Term Disability 10/10/1991 03/23/2023 04/28/2023 05/03/2023 $7,008.27

Short Term Disability 06/09/1982 03/21/2023

04/17/2023 08/10/2023 $8,546.57

Short Term Disability 01/07/1973 03/20/2023 04/20/2023 04/20/2023 $2,335.00

Short Term Disability 10/21/1954 03/14/2023

05/22/2023 05/22/2023 $3,188.96

Short Term Disability 12/18/1972 03/09/2023 04/24/2023 05/30/2023 $7,216.68

Short Term Disability 07/29/1964 03/06/2023

05/03/2023 05/03/2023 $5,225.60

Short Term Disability 11/10/1992 03/04/2023 04/06/2023 05/15/2023 $8,266.93

Short Term Disability 01/09/1986 03/03/2023

05/04/2023 05/04/2023 $164.29

Short Term Disability 09/08/1965 03/02/2023 07/19/2023 09/11/2023 $11,079.77

Short Term Disability 02/08/1985 03/02/2023

03/29/2023 08/31/2023 $31,658.72

February 2023 Incurred Total: $67,322.18

Short Term Disability 04/28/1970 02/27/2023

Run Date: 10/28/2024 1:16:25 PM

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

202678877 F Closed

202660313 U Closed

202646088 F Closed

202690486 F Closed

202625499 F Closed

202689851 F Closed

202569691 F Closed

202583850 F Closed

202809617 M Closed

202749357 F Closed

202782058 F Closed

202659681 M Closed

202723799 M Closed

202786340 F Closed

202749321 F Closed

202744367 F Closed

202764749 F Closed

202707649 F Closed

202744302 F Closed

202784850 M Closed

202812725 F Closed

202859158 M Closed

11/30/2023 11/30/2023 $3,695.94

Short Term Disability 01/17/1961 06/09/2023 10/26/2023 12/15/2023 $2,048.88

Short Term Disability 09/22/1972 06/09/2023

06/26/2023 06/26/2023 $3,480.00

Short Term Disability 08/13/1985 06/09/2023 07/26/2023 11/29/2023 $4,673.03

Short Term Disability 08/24/1990 06/09/2023

07/26/2023 09/18/2023 $4,007.04

Short Term Disability 07/19/1960 06/07/2023 07/14/2023 09/27/2023 $4,590.36

Short Term Disability 06/12/1984 06/05/2023

06/23/2023 12/27/2023 $9,044.12

Short Term Disability 12/14/1958 06/05/2023 08/02/2023 11/20/2023 $8,896.03

Short Term Disability 05/31/1959 06/03/2023

07/05/2023 07/05/2023 $3,579.43

May 2023 Incurred Total: $40,717.24

Short Term Disability 10/28/1987 05/31/2023

06/01/2023 09/13/2023 $6,718.35

Short Term Disability 01/24/1975 05/25/2023 06/30/2023 10/13/2023 $11,839.81

Short Term Disability 11/11/1966 05/25/2023

06/29/2023 07/12/2023 $3,397.30

Short Term Disability 01/04/1977 05/20/2023 07/14/2023 12/22/2023 $11,968.16

Short Term Disability 09/19/1975 05/19/2023

06/16/2023 07/21/2023 $927.67

Short Term Disability 03/17/1981 05/16/2023 08/14/2023 08/14/2023 $2,286.52

Short Term Disability 09/19/1969 05/15/2023

07/20/2023 07/20/2023 $5,784.97

April 2023 Incurred Total: $47,189.89

Short Term Disability 08/26/1988 04/27/2023

05/30/2023 05/30/2023 $3,825.11

Short Term Disability 06/08/1996 04/22/2023 06/07/2023 07/14/2023 $6,356.72

Short Term Disability 09/13/1985 04/22/2023

05/01/2023 05/08/2023 $1,344.00

Short Term Disability 02/02/1976 04/19/2023 05/15/2023 07/07/2023 $5,265.33

Short Term Disability 10/30/1994 04/19/2023

05/19/2023 05/19/2023 $2,317.60

Short Term Disability 06/12/1980 04/18/2023 05/03/2023 05/03/2023 $2,431.75

Short Term Disability 03/09/1999 04/07/2023

Run Date: 10/28/2024 1:16:25 PM

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

202772828 F Closed

202786106 M Closed

202809022 F Closed

202723999 F Closed

202764468 F Closed

202764991 F Closed

202749397 F Closed

202812081 F Closed

202773544 F Closed

202809270 F Closed

202771715 F Closed

202808909 F Closed

202810332 F Closed

202813841 M Closed

202814372 F Closed

202820334 M Closed

202824521 F Closed

202838106 F Closed

202859131 M Closed

202830125 F Closed

202811742 F Closed

202814885 F Closed

08/24/2023 10/12/2023 $1,884.56

Short Term Disability 04/05/1978 08/14/2023 08/24/2023 09/29/2023 $3,955.20

Short Term Disability 02/06/1965 08/14/2023

10/24/2023 10/24/2023 $5,770.05

Short Term Disability 03/05/1996 08/09/2023 11/07/2023 11/07/2023 $1,764.07

Short Term Disability 01/03/1986 08/03/2023

10/11/2023 10/11/2023 $2,500.71

July 2023 Incurred Total: $34,283.23

Short Term Disability 05/25/1976 07/31/2023

09/05/2023 09/05/2023 $2,426.24

Short Term Disability 03/15/1995 07/31/2023 10/25/2023 10/25/2023 $4,289.25

Short Term Disability 06/07/1974 07/26/2023

09/22/2023 09/22/2023 $2,987.83

Short Term Disability 11/22/1962 07/19/2023 01/19/2024 12/27/2023 $6,302.42

Short Term Disability 07/08/1986 07/18/2023

09/12/2023 09/12/2023 $6,988.37

Short Term Disability 07/20/1984 07/18/2023 08/28/2023 08/28/2023 $3,880.34

Short Term Disability 09/18/1992 07/17/2023

03/13/2024 08/15/2023 $674.23

Short Term Disability 08/30/1961 07/13/2023 09/15/2023 09/15/2023 $150.00

Short Term Disability 05/02/1986 07/07/2023

09/13/2023 09/13/2023 $1,478.13

Short Term Disability 12/02/2002 07/07/2023 07/27/2023 07/27/2023 $2,605.71

Short Term Disability 07/26/1983 07/05/2023

09/14/2023 09/14/2023 $1,707.12

June 2023 Incurred Total: $55,714.66

Short Term Disability 03/10/1963 06/28/2023

07/20/2023 07/20/2023 $1,550.93

Short Term Disability 09/02/1992 06/26/2023 08/23/2023 08/23/2023 $2,171.59

Short Term Disability 12/06/1989 06/17/2023

07/28/2023 08/10/2023 $2,418.50

Short Term Disability 07/06/1988 06/17/2023 08/24/2023 09/06/2023 $1,383.01

Short Term Disability 07/30/1983 06/14/2023

07/14/2023 07/14/2023 $3,609.40

Short Term Disability 07/10/2001 06/14/2023 07/24/2023 08/15/2023 $2,438.71

Short Term Disability 12/16/1985 06/13/2023

Run Date: 10/28/2024 1:16:25 PM

Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:

Selection Parameters Values on Report

306147 00306147 - STATE OF NEBRASKA

ALL 1002

07/01/2019 to 10/28/2024 07/30/2019 to 09/13/2024

202826550 M Closed

202820405 F Closed

202867399 F Closed

202856595 F Closed

202825140 M Closed

202825428 F Closed

202859113 F Closed

202830174 F Closed

202825888 F Closed

202877274 F Closed

202878325 M Closed

202903083 F Closed

202868482 M Closed

202860374 F Closed

202933982 M Closed

202921418 M…