Free 02Form12P.p65 - Nebraska

Nebraska Record of Compensation Insurance -- Form 12P

Intergovernmental Risk Management Pool
To be used to provide information on each pool member involved in the event of organization, joinder, or termination, within 10 days of the event. Only one member of a pool may be reported on a Form 12P. 1. Name and Address of Member of Risk Management Pool:

Phone: 2. 3. Name of Member: Event Reported (check one and give the effective date):

Dept. of Insurance Code:

q q q
4.

Initial Organization of Pool New Member Termination of Member

Effective Date: Effective Date: Effective Date:

For workers' compensation purposes, list any separately named entities under the jurisdiction of this member from which employees work and the location. (If additional space is needed, attach a separate sheet.) Name Address FEIN

5.

Name of Pool Administrator: Address:

6.

Prepared by (please type): Phone:

7.

Mail to:

Nebraska Workers' Compensation Court PO Box 98908 Lincoln NE 68509-8908 402-471-6468 or 800-599-5155

NWCC Form 12P (Rev. 11/06)