Nebraska Workers’ Compensation Court—SUBSEQUENT REPORT EMPLOYEE NAME (Last, First, Middle) DATE DISABILITY BEGAN SOCIAL SECURITY NUMBER PRE-EXISTING DISABILITY? YES DATE OF REPRESENTATION DATE OF DEATH NWCC FORM 4 REVISED 06/2006 DATE OF INJURY REPORT EFFECTIVE DATE JURISDICTION REPORT PURPOSE NO RELEASED/ RTW QUALIFIER RELEASED/ RETURNED TO WORK (RTW) DATE NUMBER OF DEPENDENTS DEATH DEPENDENT/ PAYEE RELATIONSHIP BODY PART RTW WITHOUT RESTRICTIONS RELEASED RTW WITHOUT RESTRICTIONS RTW WITH RESTRICTIONS RELEASED RTW WITH RESTRICTIONS AGENCY CLAIM NUMBER DATE OF MAXIMUM MEDICAL IMPROVEMENT WIDOW WIDOWER CHILDREN PERCENT SIBLINGS BODY PART PARENTS OTHER PERCENT BODY PART PERCENT PERMANENT IMPAIRMENT EMPLOYER NAME FEIN INSURED REPORT NUMBER WAGE WAGE PERIOD WEEKLY MONTHLY AVERAGE WEEKLY WAGE NUMBER OF DAYS WORKED PER WEEK SALARY CONTINUED IN LIEU OF COMP? BI-WEEKLY SEMI-MONTHLY YES NO PAYMENTS PAID FROM (MM/DD/YYYY) PAYMENT TYPE PAID THROUGH (MM/DD/YYYY) BENEFIT ADJUSTMENTS BENEFIT ADJUSTMENT TYPE # WEEKS PAID # DAYS PAID WEEKLY PAYMENT AMOUNT AMOUNT PAID TO DATE BENEFIT ADJUSTMENTS WEEKLY AMOUNT (+ OR -) START DATE PAID-TO-DATE BENEFIT ADJUSTMENT TYPE WEEKLY AMOUNT (+ OR -) START DATE PAID-TO-DATE PAID TO DATE TYPE PAID TO DATE AMOUNT PAID TO DATE TYPE PAID TO DATE AMOUNT CLAIM ADMINISTRATION INSURER NAME FEIN THIRD PARTY ADMINISTRATOR NAME FEIN CLAIM ADMINISTRATOR CLAIM NUMBER CLAIM TYPE OPEN REOPENED CLOSED REOPENED/CLOSED MEDICAL ONLY INDEMNITY CLAIM STATUS NOTIFICATION ONLY AGREEMENT TO COMPENSATE CLAIM ADMINISTRATOR ADDRESS BECAME MED ONLY BECAME LOST TIME TRANSFER WITHOUT LIABILITY WITH LIABILITY LATE REASON PHONE # DATE PREPARED CITY FORM PREPARER’S NAME STATE ZIP CODE PREPARER’S PHONE American LegalNet, Inc. www.FormsWorkflow.com General Instructions Items in bold are mandatory fields. Subsequent Report of Injury (SROI) without this information will be returned. Item—Definitions • • • • • • • • • • • • • • • • • • • • • Employee Name—the injured worker’s legally recognized name. Social Security Number—a number assigned by the Social Security Administration used to identify the employee. Date of Injury—date on which the accident occurred (only one date of injury per form). Report Effective Date—The date the payment which causes the form to be filed was made. Jurisdiction—the governing body or territory whose statutes apply (NE). Date Disability Began—the first day on which the employee originally lost time from work due to the occupational injury or disease or as otherwise defined by the jurisdiction. Pre-Existing Disability—identifies the existence of a disability that existed prior to the injury. Date of Representation—the date the claim administrator became aware that the claimant had secured legal representation. Date of Death—the date the injured worker died. Report Purpose—The MTC (maintenance type code) that corresponds to the reason the form is being filed. Released/Returned to Work (RTW) Date—the date, following the most recent disability period, on which the employee actually returned to work, or was released to return to work, as identified by the return to work qualifier. Released/RTW Qualifier—a code identifying the employee’s return to work status, with or without physical restrictions. Agency Claim Number—the number assigned by the Nebraska Workers’ Compensation Court to identify a specific claim. Number of Dependents—the number of dependents as defined by the Nebraska Workers’ Compensation Act. Death Dependent/Payee Relationship—the relationship of the dependent(s)/payee(s) to the deceased employee; to which relationship and benefit entitlement may be determined by an adjudicator’s decision for distribution of the death benefit. Date of Maximum Medical Improvement—the date after which further recovery from or lasting improvement to an injury or disease can no longer be anticipated based upon reasonable medical probability. Permanent Impairment Body Part Code—a code referencing the part(s) of body permanently impaired. Permanent Impairment Percentage—report the amount of part(s) of body or functional abnormality or loss which results from the injury and exists after the date of maximum medical improvements. Employer Name—the name of the business entity of the insured where the employee was employed at the time of the injury. Employer FEIN—the Federal Employer’s Identification Number of the employer where the employee was employed at the time of the injury. Insured Report Number—a number used by the insured to identify a specific claim. Wage • Wage Period—a code indicating the time period during which the wage was earned. • Average Weekly Wage—the average wage of the employee at the time of injury as calculated by the claims administrator or jurisdictional authority for the wage period. • Number of Days Worked Per Week—the number of the employee’s regularly scheduled work days per week. • Salary Continued In Lieu of Comp—the employer has paid or is paying the employee’s salary in lieu of compensation during an absence caused by a work-related injury. Payments • Payment Type—a code that identifies the payment being made. • Payment From Date—the first start date of a benefit period for which benefits were paid. • Payment Through Date—the last date of a benefit period for which benefits were paid. • Payment Weeks Paid—the number of whole weeks for a specific payment code. • Payment Days Paid—the number of days paid for a specific payment code. • Payment Weekly Amount—the net weekly rate for the payment code being paid. • Payment Paid to Date—the cumulative amount paid for the payment code being paid. Benefit Adjustments • Benefit Adjustment Type— DO NOT USE. Reserved for future use. • Benefit Adjustment Weekly Amount— DO NOT USE. Reserved for future use. • Benefit Adjustment Start Date— DO NOT USE. Reserved for future use. Paid-To-Date • Paid to Date Type—a code that identifies the type of paid to date/reduced earnings/recoveries made. • Paid to Date Amount—the amount defined by the paid to date/reduced earnings/recoveries code. Claim Administrator • Insurer Name—the name of the insurer or self insured assuming the employer’s financial responsibility for workers’ compensation claim(s). • Insurer FEIN—insurer’s Federal Employer’s Identification Number. • Third Party Administrator Name—the name of the Third Party Administrator contracted to adjust the claim on behalf of the carrier or self insured. • Third Party Administrator FEIN—the Federal Employer’s Identification Number of the third party administrator’s independent adjuster, contracted to adjust the claim on behalf of the insurer or self insured. • Claim Administrator Claim Number—identifies a specific claim within a claim administrator’s claims processing system. • Claim Administrator Address—the address, including zip code, and telephone number of the claim administrator. • Form Preparer’s Name— the name of the person completing the form. Claim Status • Claim Status—a code representing the current status of the claim. • Claim Type—a code representing the current benefit classification of the claim as interpreted by the jurisdiction • Agreement to Compensate—a code used to identify the condition under which compensation benefits are being paid. • Late Reason—a code which identifies the reasons payment/report was not made within a jurisdiction’s requirements. • Date Prepared—the date the form preparer completed the form. • Preparer’s Phone—the phone number of the person completing the form. Type or print neatly your response in ink. American LegalNet, Inc. www.FormsWorkflow.com