Free Form 12: Record of Compensation Insurance - Nebraska

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. Insured's Name & Address

Assigned Risk? 2. Policy Number

[ Yes [ No
3. NE Dept. of Ins. Company Number (5 digit) 11. Any Prior Business Names 5. If No Deductible Not Chosen Not Offered

4. Deductible Amount

[ [

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 [ [
Renewal or Extension Nonrenewal

Cancellation Date
For Effective Date See NE Rev. Stat. 48-144.03 or Rule 32. Must be sent by certified mail.

(Effective 30 days after certified mailing)

[ Reinstatement

Reinstatement Date

9. Reason for Cancellation or Nonrenewal

13. Insured's Federal Identification Number (FIN)

Prepared By (Please Type)

Preparer's Telephone #

Date

NWCC FORM 12 (REV. 6/95)