Nebraska Workers' Compensation Court First Report of Alleged Occupational Injury or Illness Employer Employer FEIN Employer Name(s) Address Insured Address (If different) City State Zip Code Phone Location SIC Code Report Purpose OSHA Log Case # Insured Name (If different from employer name) NWCC Form 1 Revised 1 /20 Insurance Carrier Carrier FEIN Name Address Administrator FEIN Claim Administrator (Name, address & phone number) City State Zip Code Phone Self Insured Check if Appropriate Insured Report # Claim Administrator Claim # Jurisdiction Claim # Jurisdiction Policy Number Policy Period: From To Insurance Carrier/Self-Insured Code # Employee Name (Last, First, Middle) Address Full Pay for DOI Yes Salary Continued Yes Number of Dependents Marital Status Married Separated Unmarried Unknown Wage $ Hourly Daily Weekly Bi-Weekly Monthly No No Number of Days Worked PerWeek Occupational Job Title Occupational Code NCCI Class Code Date Employee Began Work-Related Duties Sex Male Female City State Date of Birth Zip Code Phone Social Security Number Date Hired Employment Status FT PT Other Occurrence/Treatment Date of Injury/Illness Where Did Injury/Illness Occur? County Date Employer Notified Time Employee Began Work AM PM Last Work Date AM (Cannot be determined ) PM Did Injury/Illness Occur On Employer's Premises? Yes No Date Returned to Work If Fatal, Give Date of Death Nature of Injury Code Time of Occurrence State Zip Date Disability Began Type of Injury/Illness (Briefly describe the nature of the injury or illness; e.g. lacerations to forearm) Part of Body Affected (Indicate the part of the body affected by the injury/illness; e.g. right forearm, lowerback; and how it was affected) Part of Body Code How Injury/Illness Occurred (Describe activity and tools, materials, equipment the employee was using; how injury occurred) Cause of Injury Code Initial No medical treatment Emergency No Medical Treatment Room FirstFuture major Name of physician or Clinic/Hospital provider: Emergency Care Aid By Employer Minor other health care Treatment: First aid by employer medical/lost Hospitalized overnight Hospitalized More Than 24 Hours Future Major Medical/Lost Time time Minor clinic/hospital Hospitalized > 24 hours Date Administrator Notified Form Preparer's Name, Title and Phone Date Prepared American LegalNet, Inc. www.FormsWorkFlow.com General Instructions Underlined items are mandatory fields. A first report of injury or illness submitted without this information will be returned unfiled. Employer: ˇ Employer FEIN -- the employer/insured's Federal Employer's Identification Number. ˇ SIC Code -- Standard Identification Classification code which represents the nature of the employer's business. ˇ Report Purpose -- defines the specific purpose of the transaction (examples: original = 00; cancel = 01; change = 02; denial = 04; correction = CO). ˇ OSHA Log Case # -- the Log Case number required for reporting to OSHA. ˇ Employer Name -- include all business names/doing business as (dba). ˇ Address (including city,state, and zip code) -- the address of the employer's actual location where the employee was employed at the time of the injury. ˇ Phone -- phone number at the employer's facility. ˇ Insured Name (if different from employer) -- the named insured on the policy or the financially responsible self­insured employer. ˇ Insured Address (if different from employer) -- mailing address of the insured. ˇ Location -- a code defined by the insured/employer which is used to identify the employer's location. Insurance Carrier: ˇ Carrier FEIN -- carrier's Federal Employer's Identification Number. ˇ Administrator FEIN -- administrator's Federal Employer's Identification Number. ˇ Name -- the workers' compensation insurer, approved self insured, or intergovernmental risk management pool. ˇ Address -- address, city, state and zip code of insurer. ˇ Phone -- phone number of insurer. ˇ Claim Administrator (name, address, & phone) -- enter the name, address and phone number of the carrier, third party administrator, risk management pool, or selfinsurer responsible for administering the claims, if different from carrier information. ˇ Policy # -- the number assigned to the contract/policy for that employer. ˇ Policy Period -- the effective and expiration dates of the contract/policy. ˇ Insurance Carrier/Self Insured Code # -- for insurance carriers, the number assigned by the Nat'l Assn. of Insurance Commissioners. For self-insured employers, the code number assigned by the court. ˇ Self Insured -- check if appropriate. ˇ Claim Administrator Claim # -- identifies a specific claim within a claim administrator's claims processing system. ˇ Jurisdiction Claim # -- number assigned by the court when the initial First Report is accepted. ˇ Insured Report # -- a number used by the insured to identify a specific claim. ˇ Jurisdiction -- the governing body or territory whose statutes apply (NE). Employee: ˇ Name -- give full name as shown on payroll (avoid initials if possible). ˇ Address -- address, city, state and zip code of employee. ˇ Social Security Number. The social security number must be provided. This is mandatory pursuant to Neb.Rev.Stat. §48-144, Rule 29 of the Workers' Compensation Court Rules of Procedure, and Section 7(a)(2)(B) of the Privacy Act of 1974. The social security number is used by the Nebraska Workers' Compensation Court for purposes of verifying the identity of the employee and administering the Nebraska Workers' Compensation Act. It is a unique identifier and is needed because of the number of persons who have similar names and birth dates, and whose identities can only be distinguished by social security number. The social security number may also be shared with claims handling entities for purposes of processing a claim for workers' compensation benefits and verifying the identity of the claimant. ˇ Date of Birth -- the date the injured worker was born. ˇ Date Hired -- the date the injured worker began his/her employment with the employer. ˇ Full Pay for DOI (date of injury) -- check one. ˇ Salary Continued -- check one. ˇ Number of Days Worked Per Week -- the number of the employee's regularly scheduled work days per week. ˇ Sex -- check one. ˇ Number of Dependents -- the number of dependents as defined by the Nebraska Workers' Compensation Act. ˇ Marital Status -- check one. ˇ Wage -- check one and state wage. ˇ Occupational Job Title -- the primary occupation of the claimant a