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.
Question | Answer |
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Form Name | Nwcc Form 1 |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | nebraska first illness court, nebraska first occupational court, nebraska first injury form, nebraska first report injury form |
Nebraska Workers’ Compensation Court
First Report of Alleged Occupational Injury or Illness
NWCC Form 1 Revised 1 /20
Employer
Employer FEIN |
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SIC Code |
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Report Purpose |
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OSHA Log Case # |
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Employer Name(s) |
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Insured Name (If different from employer name) |
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Address |
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Insured Address (If different) |
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Location |
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State |
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Insurance |
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Carrier |
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Carrier FEIN |
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Administrator FEIN |
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Name |
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Claim Administrator (Name, address & phone number) |
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Address |
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City |
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State |
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Zip Code |
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Phone |
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Claim Administrator Claim # |
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Self Insured |
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Policy Number |
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Check if |
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Jurisdiction Claim # |
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Appropriate |
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Policy Period: |
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Insurance |
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Insured Report # |
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Jurisdiction |
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Employee |
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Name (Last, First, Middle)
Address
City
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Phone |
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Date of Birth |
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Social Security Number |
Date Hired |
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Full Pay for DOI |
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No |
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Number of Days |
Sex |
Male |
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Salary Continued |
Yes |
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No |
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WorkedPerWeek |
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Female |
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Occupational Job Title |
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Number of Dependents |
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Marital Status |
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Wage$ |
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Occupational Code |
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Married |
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Hourly |
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NCCI Class Code |
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Separated |
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Daily |
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Unmarried |
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Weekly |
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Date Employee Began |
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Unknown |
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Monthly |
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Employment Status FT |
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PT |
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Other |
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Occurrence/Treatment
Date of Injury/Illness |
Time Employee Began Work |
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Time of Occurrence |
AM |
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Last Work Date |
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PM |
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(Cannot be determined |
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PM |
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Where Did Injury/Illness Occur? |
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Did Injury/Illness Occur On Employer’s Premises? |
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County |
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Yes |
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No |
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Date Employer Notified |
Date Disability Began |
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Date Returned to Work |
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If Fatal, Give Date of Death |
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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
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Initial |
No medical |
treatment |
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Emergency Room |
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Name of physician or other health care provider: |
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Treatment: First aid by |
No Medi |
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Treatment |
Fir |
stFutureAid BymajorEmployer |
Minor Clinic/Hospital |
Emergency Care |
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employer |
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Hospitalized overnight |
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medical/lost |
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Hospitalized M |
ore Than 24 Hours |
Future Major Medical/Lost Time |
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Minor clinic/hospital |
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Hospitalized > 24 hours |
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time |
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Date Administrator Notified |
Form Preparer’s Name, Title and Phone |
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Date Prepared |
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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:
•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
•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 — 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).
Employee:
•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.
•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
•Employment Status — check one.
Occurrence/Treatment:
•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
•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
•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.