First Report of Alleged Occupational Injury or Illness

1.	This is a legal document filed with the Nebraska Workers’ Compensation Court. It serves as evidence of the alleged occurrence and begins the paper trail.

2.	Should be filled out by the injured employee’s supervisor. The employee should not fill out the First Report.

3.	Employee information should be filled out completely.

4.	Occurrence/Treatment Section should be filled out completely.

a.	Type of Injury is a bruise, laceration, etc.

b.	Body Part named with the right or left side.

c.	How the Injury Occurred describes what the employee was doing, equipment being used, and how it happened.

5.	Choose your words carefully. Use the word alleged if there is any doubt that the accident happened or there are no witnesses.

Human Resources’ Fax No.: (402) 479-3765

First Report of Alleged Occupational Injury or Illness

Employer
Employer FEIN	47-0491233	SIC Code	Report Purpose	OSHA Log Case #
Employer Name(s)	State of Nebraska, Dept. of Transportation	Insured Name (If different from employer name)
Address	Human Resources Division
PO Box 94759	Insured Address (If different)	Location
City	Lincoln
State	NE	Zip Code	68509-4759	Phone	(402) 479-4574
Insurance Carrier
Carrier FEIN	Administrator FEIN
Name	State of Nebraska – Human Resources	Claim Administrator (Name, address, and phone number) Gallagher Bassett 10050 Regency Cir Ste 300 Omaha, NE 68114
Address	PO Box 94759
City	Lincoln
State	NE	Zip Code	68509-4759	Phone	Self-Insured Check if Appropriate	Claim Administrator Claim #
Policy No.	N/A	Claim Reference #
Policy Period:	From	N/A	To	N/A	Jurisdiction Claim #
Insurance Carrier/Self-Insured Code #	S1096	Insured Report #	Jurisdiction
Employee
NIS/Workday #: Name (Last, First, Middle): Address: City: State: Zip Code: Cell Phone: Work Phone:	Full Pay for DOI Yes No Salary Continued Yes No	Number of Days Worked per Week	Sex Male Female
Number of Dependents:	Occupational Job Title:
Hourly Rate:	$
Date of Birth:	Occupational Code:
Date Hired:	NCCI Class Code:
Marital Status: Married Unmarried Separated Unknown	Date Employee Began Work-Related Duties
Employment Status FT PT Other
Occurrence/Treatment
Date of Injury/Illness:	Time Employee Began Work: AM PM	Time of Occurrence: AM ( Cannot be determined) PM	Last Work Date:
Where Did Injury/Illness Occur? County State Zip	Did Injury/Illness Occur on Employer’s Premises? Yes No
Date Employer Notified:	Time 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, eg. lacerations to forearm)	Nature of Injury Code:
Part of Body Affected (Indicate the part of the body affected by the injury/illness, eg. right forearm, lower back; and how it was affected)	Part of Body Code:
How Injury/Illness Occurred (Describe activity and tools, materials, equipment the employee was using; how injury occurred)	Cause of Injury Code:
Initial No Medical Treatment Emergency Room Future major medical/ Treatment: First-Aid by Employer Hospitalized overnight lost time Minor Clinic/Hospital Hospitalized > 24 hours	Name of physician or other health care provider:
Date Administration Notified:	Supervisor’s Signature, Title and Phone Required:	Date Prepared:

NDOT Form 367, July 17	NWCC Form 1

Revised 11-06
General Instructions

Items in bold are mandatory fields. First Report of Injury or Illness (FROI) without this information will be returned.

Item – Definitions

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, zip) – 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 name insured on the policy or the financially responsible self-insured employer.

Insured Address (if different) – 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 worker’s compensation insurer, approved self insured, or intergovernmental risk management pool.

Address – address of insurer (including city, state, zip).

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.

Insurance Carrier/Self Insured Code # – for insurance carriers, the number assigned by the Nat’l. Assn. of Insurance Commissioners. For selfinsured 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 # – a number assigned by the court when the initial First Report is accepted.

Insured’s 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 – enter employee’s current city and state. (Address and zip code information is optional.)

Date of Birth – the date the injured worker was born.

NIS/Workday No.

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 administering jurisdiction.

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.

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.

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. (Conditional if employee died as a result of a 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.

Date Prepared – date form was actually completed.

Type or print neatly your response in ink.