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:
