Nwcc Form 1 PDF Details

If you are a new business owner in the state of North Carolina, then you will need to apply for an Nwcc Form 1. This document is used to register your company with the state and receive your tax ID number. The process is simple and can be completed online. In this article, we will walk you through the steps necessary to register your business. Let's get started! The first step is to visit the website of the North Carolina Secretary of State. You can find this website by clicking here . Once you have reached the homepage, click on "Business Registration" in the top menu bar. From there, choose "Form 1 - New Business.

Here is some data that might be useful in case you are aiming to find out how long it'll require you to complete nwcc form 1 and what number of PDF pages it has.

Form NameNwcc Form 1
Form Length2 pages
Fillable fields102
Avg. time to fill out20 min 54 sec
Other namesnebraska nwcc form, ne first injury form, nwcc 1 form, first report of alleged occupational injury

Form Preview Example

Nebraska Workers’ Compensation Court

First Report of Alleged Occupational Injury or Illness

NWCC Form 1 Revised 1 /20


Employer FEIN





SIC Code




Report Purpose




OSHA Log Case #







































Employer Name(s)











Insured Name (If different from employer name)























































































































Insured Address (If different)




























































































Zip Code




























































































Carrier FEIN

















Administrator FEIN

































































Claim Administrator (Name, address & phone number)










































































































































Zip Code




































Claim Administrator Claim #

















Self Insured















Policy Number
















Check if































Jurisdiction Claim #



























Policy Period:















































Insurance Carrier/Self-Insured Code #






































Insured Report #







































































































































Name (Last, First, Middle)




Zip Code













Date of Birth


Social Security Number

Date Hired









Full Pay for DOI













Number of Days































































Salary Continued
























































Occupational Job Title











Number of Dependents







































































































Marital Status










































Occupational Code


























































































NCCI Class Code










































































































































































































Date Employee Began






































Work-Related Duties































































































































































Employment Status FT
















































Date of Injury/Illness

Time Employee Began Work



Time of Occurrence




Last Work Date





















































(Cannot be determined








































































































Where Did Injury/Illness Occur?










Did Injury/Illness Occur On Employer’s Premises?


















































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)

Nature of Injury Code

Part of Body Code

Cause of

Injury Code

















No medical




Emergency Room




Name of physician or other health care provider:




Treatment: First aid by

No Medi




stFutureAid BymajorEmployer

Minor Clinic/Hospital

Emergency Care







Hospitalized overnight













Hospitalized M

ore Than 24 Hours

Future Major Medical/Lost Time

































Minor clinic/hospital



Hospitalized > 24 hours







































Date Administrator Notified

Form Preparer’s Name, Title and Phone



Date Prepared

















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.

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:

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.

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).


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.

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.


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.

How to Edit Nwcc Form 1 Online for Free

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step 1 to writing nebraska report injury form

In the Policy, Period, From Appropriate, Insurance, Carrier, Self, Insured, Code Insured, Report Jurisdiction, Employee, Name, Last, First, Middle Address, City, State, Zip, Code Phone, DateofBirth, Social, Security, Number and Date, Hired area, put in writing your details.

nebraska report injury form PolicyPeriodFrom, Appropriate, InsuranceCarrierSelfInsuredCode, InsuredReport, Jurisdiction, Employee, NameLastFirstMiddle, Address, City, State, ZipCode, Phone, DateofBirth, SocialSecurityNumber, and DateHired fields to insert

Inside the section referring to Part, of, Body, Code Cause, of, Injury, Code Initial, Treatment Future, major, medical, lost, cid, time Date, Administrator, Notified Form, Preparer, s, Name, Title, and, Phone and Date, Prepared it's essential to put down some demanded data.

Filling in nebraska report injury form step 3

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