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Insured Name (If different from employer name)

Insured Address (If different)

Administrator FEIN

Claim Administrator (Name, address & phone number)

Insured Report # Jurisdiction

Full Pay for DOI Yes No

Salary Continued Yes No

Number of Dependents

Marital Status Wage $

Married Hourly

Separated Daily

Unmarried Weekly

Unknown Bi-Weekly

Monthly

NWCC Form 1

Revised 1/20

Sex Male

Female

Nature of

Injury Code

Part of

Body Code

Cause of

Injury Code

Initial

Treatment:

AM

PM

Number of Days

Worked Per Week

Occupational Job Title

Occupational Code

NCCI Class Code

Date Employee Began

Work-Related Duties

Employment Status FT PT Other

Occurrence/Treatment

Date of Injury/Illness Time Employee Began Work Time of Occurrence Last Work Date

Where Did Injury/Illness Occur? Did Injury/Illness Occur On Employer’s Premises?

County State Zip Yes No

Date Employer Notified Date Disability Began Date Returned to Work If Fatal, Give Date of Death

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)

How Injury/Illness Occurred (Describe activity and tools, materials, equipment the employee was using; how injury occurred)

No Medical Treatment First Aid By Employer Minor Clinic/Hospital Emergency Care

Hospitalized More Than 24 Hours Future Major Medical/Lost Time

Date Administrator Notified Form Preparer’s Name, Title and Phone Date Prepared

Location

Nebraska Workers’ Compensation Court

First Report of Alleged Occupational Injury or Illness

Employer

Employer FEIN SIC Code Report Purpose OSHA Log Case #

Employer Name(s)

Address

City

State Zip Code Phone

Insurance Carrier

Carrier FEIN

Name

Address

City

State Zip Code Phone

Policy Number

Policy Period: From To

Insurance Carrier/Self-Insured Code #

Employee

Name (Last, First, Middle)

Address

City

State Zip Code Phone

Date of Birth Social Security Number Date Hired

AM

PM

No medical treatment

First aid by employer

Minor clinic/hospital

Emergency Room

Hospitalized overnight

Hospitalized > 24 hours

Future major

medical/lost

time

Name of physician or other health care provider:

(Cannot be determined )

Self Insured

Check if

Appropriate

Claim Administrator Claim #

Jurisdiction Claim #

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General Instructions

Underlined items are mandatory fields. A first report of injury or illness submitted without this information will be returned unfiled.

• 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.

• Carrier FEIN — carrier’s Federal Employer’s Identification Number.

• Administrator FEIN — administrator’s Federal Employer’s Identification Number.

• Name — the workers’ 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 self- insurer 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.

• Name — give full name as shown on payroll (avoid initials if possible).

• Address — address, city, state and zip code of employee.

• Social Security Number. The social security number must be provided. This is

mandatory pursuant to Neb.Rev.Stat. §48-144, Rule 29 of the Workers’ Compensation

Court Rules of Procedure, and Section 7(a)(2)(B) of the Privacy Act of 1974. The

social security number is used by the Nebraska Workers’ Compensation Court for

purposes of verifying the identity of the employee and administering the Nebraska

Workers’ Compensation Act. It is a unique identifier and is needed because of the

number of persons who have similar names and birth dates, and whose identities

can only be distinguished by social security number. The social security number

may also be shared with claims handling entities for purposes of processing a claim

for workers’ compensation benefits and verifying the identity of the claimant.

• Date of Birth — the date the injured worker was born.

• 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.

• 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.

• Phone — phone number at the employer’s facility.

• Insured Name (if different from employer) — the named insured on the policy or the

financially responsible self–insured 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/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).

• 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 Work-Related Duties — date pertaining to employee’s present

occupation.

• Employment Status — check one.

• 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.

Employer:

Insurance Carrier:

Employee:

Occurrence/Treatment: