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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 Insured Name If different from employer name Employer Name s Address Insured Address If different Location City State Zip Code Phone Insurance Carrier Carrier FEIN Administrator FEIN Claim Administrator Name address phone number Name Policy Number Policy Period From Self Insured Check if Appropriate To Jurisdiction...
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TitleInsured NumberInsured Claim TypesClaim Type Code Insured Employee Claims (if employee age over 18)Claim Type Code Insured Employee Claims (if employee age over 12)Claim Type Code Insured Employee Claims (if employee age 13 or less)Claim Type Code Claims Result Date Claim Type Code Claims Result Date Insured Claim Owner Insured Employer Claim Owner Insured Employer Date Claim Location Insured Claim Owner Insured Employer (if any) Claim Owner Insured Employer (if any) Date Claim Type Code Claims Result Date Claims Type Claim Type Insured Employee Claim (if older than 13) Claim Type Code Claims Result Date Claim Type Insured Employee Claim (if over 13) Claim Type Code Claim Type Code Insured Employee Claim (if under 13) Insured Claim Owner Insured Employer Claim Owner Insured Employer For additional information, go to The OSHA-OIG Labor-Management Reporting System was established to simplify information on injuries, deaths and employment disputes between employers and employees. These data are reported to OSHA through the Department of Labor's “MFR” format, which is a common language for employers and employees to report injury or illness claims. The following information is part of this MFR format. You may find additional OSHA-OIG related documents, including the OSHA-OIG MFR Form 1.4 and OSHA-OIG MFR Form 1.4A, at the OSHA website. The information on this page is accurate to the best of OSHA's knowledge. However, OSHA does not assume any responsibility for the accuracy of the information, and it should not be construed as an endorsement by OSHA or the U.S. Department of Labor.