NEBRASKA RECORD OF COMPENSATION INSURANCE To be Used to Report Compensation Insurance Issuance, Cancellation, Renewal, Nonrenewal, or Reinstatement. MAIL TO: NEBRASKA WORKERS COMPENSATION COURT, P.O. BOX 98908, LINCOLN, NE 68509-8908 (402) 471-6468 1. Name and Address of Insurance Carrier 10. Insureds Name & Address Assigned Risk? Yes No 2. Policy Number 3. NE Dept. of Ins. Company 11. Any Prior Business Names Number (5 digit) 4. Deductible Amount 5. If No Deductible Not Chosen Not Offered 6. Effective Date 7. Expiration Date 12. List All Nebraska location addresses with the current business name (If additional space is needed, use back of form or attach separate sheet.) 8. Transaction (Complete One) New Policy Cancellation Cancellation Date For Effective Date See NE Rev. Stat. 48-144.03 or Rule 32. Must be sent by certified mail. Renewal or Extension Nonrenewal (Effective 30 days after certified mailing) Reinstatement Reinstatement Date 9. Reason for Cancellation or Nonrenewal 13. Insureds Federal Identification Number (FIN) Prepared By (Please Type) Preparers Telephone # DateNWCC FORM 12 (REV. 6/95)