Get Crystal Reports - Nebraska Workers' Compensation Court - First Report Of Injury

This guide provides clear, step-by-step instructions for users filling out the Crystal Reports - Nebraska Workers' Compensation Court - First Report Of Injury online. The aim is to ensure accurate and comprehensive reporting of workplace injuries or illnesses.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to access the form and open it in your preferred editing application.
2. Begin by entering the employer's information. Fill in the employer name, SIC code, Employer FEIN, OSHA log case number, and address details. Be sure to specify if the insured name differs from the employer name.
3. Next, provide the insurance carrier's details including the carrier FEIN, the administrator's FEIN, and the name and contact information for the claim administrator.
4. Complete the employee's information section. Include the employee's full name, address, and social security number as well as their date of birth, marital status, and occupational job title.
5. Indicate the occurrence/treatment section by entering the date of injury/illness, time of occurrence, county and state where it happened, and the date the employer was notified.
6. Describe the nature of the injury/illness, including its type and the part of the body affected. Use clear language to outline how the injury/illness occurred.
7. Detail the initial treatment that the employee received and provide the name of the health care provider, if applicable. Also record if medical treatment was necessary.
8. Lastly, ensure to fill out the form preparer's information including name, title, and contact number. Confirm that all sections are completed accurately.
9. After completing the form, save your changes and opt to download, print, or share the document as needed.

Complete and submit your documents online today for efficient injury reporting.