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.

QuestionAnswer
Form NameNwcc Form 1
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesnebraska first illness court, nebraska first occupational court, nebraska first injury form, nebraska first report injury form

Form Preview Example

Nebraska Workers’ Compensation Court

First Report of Alleged Occupational Injury or Illness

NWCC Form 1 Revised 1 /20

Employer

Employer FEIN

 

 

 

 

SIC Code

 

 

 

Report Purpose

 

 

 

OSHA Log Case #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name(s)

 

 

 

 

 

 

 

 

 

 

Insured Name (If different from employer name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insured Address (If different)

 

Location

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

Zip Code

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance

 

Carrier

 

 

 

 

 

 

 

 

 

 

 

Carrier FEIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Administrator FEIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claim Administrator (Name, address & phone number)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

Zip Code

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claim Administrator Claim #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self Insured

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check if

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Jurisdiction Claim #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appropriate

 

 

Policy Period:

 

From

 

 

 

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance Carrier/Self-Insured Code #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insured Report #

 

 

 

 

 

 

 

 

Jurisdiction

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (Last, First, Middle)

Address

City

State

Zip Code

 

Phone

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

Social Security Number

Date Hired

 

 

 

 

 

 

 

 

Full Pay for DOI

Yes

 

 

No

 

 

 

 

 

 

 

 

Number of Days

Sex

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Salary Continued

Yes

 

 

No

 

 

 

 

 

 

 

WorkedPerWeek

 

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Occupational Job Title

 

 

 

 

 

 

 

 

 

 

Number of Dependents

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital Status

 

Wage$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Occupational Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Married

 

 

 

 

 

 

 

 

 

Hourly

 

 

 

 

 

 

NCCI Class Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Separated

 

 

 

 

 

 

 

 

 

Daily

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unmarried

 

 

 

 

 

 

 

Weekly

 

 

 

Date Employee Began

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Work-Related Duties

 

 

 

 

 

 

 

 

 

 

 

 

 

Unknown

 

 

 

 

Bi-Weekly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Monthly

 

 

 

 

Employment Status FT

 

 

PT

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Occurrence/Treatment

Date of Injury/Illness

Time Employee Began Work

 

 

Time of Occurrence

AM

 

 

Last Work Date

 

 

 

 

 

 

 

 

 

 

 

AM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

 

 

(Cannot be determined

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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)

Nature of Injury Code

Part of Body Code

Cause of

Injury Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Initial

No medical

treatment

 

 

Emergency Room

 

 

 

Name of physician or other health care provider:

 

 

 

Treatment: First aid by

No Medi

cal

Treatment

Fir

stFutureAid BymajorEmployer

Minor Clinic/Hospital

Emergency Care

 

 

 

employer

 

 

Hospitalized overnight

 

medical/lost

 

 

 

 

 

 

 

 

 

 

Hospitalized M

ore Than 24 Hours

Future Major Medical/Lost Time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Minor clinic/hospital

 

 

Hospitalized > 24 hours

 

time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Administrator Notified

Form Preparer’s Name, Title and Phone

 

 

Date Prepared

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 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).

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. §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.

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 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.

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