Free 2006-11_Form1.pmd - Nebraska

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 11/2006

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? No Yes 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

General Instructions (Item--Definitions)
Items in bold are mandatory fields. First Report of Injury or Illness (FROI) without this information will be returned.
Employer: · Employer FEIN--the employer/insured's Federal Employer's Identification Number. · SIC Code--Standard Identification Classification code which represents the nature of the employer's business. · Report Purpose--defines the specific purpose of the transaction (examples: original=00; cancel=01; change=02; denial;=04; correction=co). · OSHA Log Case #--the Log Case number required for reporting to OSHA. · Employer Name--include all business names/doing business as (dba) · 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. · Phone--phone number at the employer's facility. · Insured Name (if different from employer)--the named insured on the policy or the financially responsible self­insured employer. · Insured Address (if different from employer)--mailing address of the insured. · Location--a code defined by the insured/employer which is used to identify the employer's location. Insurance Carrier: · Carrier FEIN--carrier's Federal Employer's Identification Number. · Administrator FEIN--administrator's Federal Employer's Identification Number. · Name--the worker's compensation insurer, approved self insured, or intergovernmental risk management pool. · Address-- address, city, state and zip code of insurer. · Phone--phone number of insurer. · 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. · Policy #--the number assigned to the contract/policy for that employer. · Policy Period--the effective and expiration dates of the contract/policy. · 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. · Self Insured--check if appropriate. · Claim Administrator Claim #--identifies a specific claim within a claim administrator's claims processing system. · Jurisdiction Claim #--number assigned by the court when the initial First Report is accepted. · Insured Report #--a number used by the insured to identify a specific claim. · Jurisdiction--the governing body or territory whose statutes apply (NE). Employee: · Name--give full name as shown on payroll (avoid initials if possible). · Address-- address, city, state and zip code of employee. · Date of Birth--the date the injured worker was born. · Social Security Number. · Date Hired--the date the injured worker began his/her employment with the employer. · Full Pay for DOI (date of injury)--check one. · Salary Continued--check one. · Number of Days Worked Per Week--the number of the employee's regularly scheduled work days per week. · Sex--check one. · Number of Dependents--the number of dependents as defined by the Nebraska Workers' Compensation Act. · Marital Status--check one. · Wage--check one and state wage. · Occupational Job Title--the primary occupation of the claimant at the time of the accident. · Occupational Code--Standard Occupational Classification code used to identify the primary occupation of the employee at the time of the accident. · NCCI Code--The identifying number for an occupational classification. · Date Employee Began Work­Related Duties--date pertaining to employee's present occupation. · Employment Status--check one. Occurrence/Treatment: · Date of Injury/Illness--date on which the accident occurred (only one date of injury per form). · Time Employee Began Work--time employee began work for that date. · Time of Occurrence--time of day the injury occurred. · Last Work Date--the last paid work day prior to the initial date of disability. · Where Did Injury/Illness Occur--complete county, state, and zip code. · Did Injury/Illness Occur On Employer's Premises--check one. · Date Employer Notified--the date that the injury was reported to a representative of the employer. · Date Disability Began--if not disabled answer none and skip questions. · Date Returned to Work--if injured has returned to work, complete this question. · If Fatal, Give Date of Death, (date employee died as a result of the work-related injury.) · Type of Injury/Illness--describe the nature of injury. · Nature of Injury Code--the code which corresponds to the nature of the injury sustained by the employee. · Part of Body Affected--the part of the body to which the employee sustained injury. · Part of Body Code--the code which corresponds to the Part of the body to which the employee sustained injury. · How Injury/Illness Occurred--a free-form description of how the accident occurred and the resulting injuries. · Cause of Injury Code--the code that corresponds to the cause of injury · Initial Treatment--check one. · Name of physician or other health care provider--provide name of physician or other health care provider that treated employee for injury. · Date Administrator Notified--the date the claim administrator who is processing the claim received notice of the loss or occurrence. · Form Preparer's Name, Title and Phone. · Date Prepared--date form was actually completed.

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