Nebraska > Workers Comp
Subsequent Report 4 - Nebraska
| Subsequent Report Form. This is a Nebraska form and can be used in Workers Comp . |
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NWCC FORM 4 Nebraska Workers Compensation CourtSUBSEQUENT REPORT REVISED 03-02 EMPLOYEE NAME (Last, First, Middle) SOCIAL SECURITY NUMBER DATE OF INJURYREPORT EFFECTIVE DATE JURISDICTION DATE DISABILITY BEGANPRE-EXISTING YESDATE OF REPRESENTATION DATE OF DEATH REPORT PURPOSE DISABILITY? NO RELEASED/ RETURNED RELEASED/ RTW WITHOUT RESTRICTIONS RELEASED RTW WITHOUT RESTRICTIONS AGENCY CLAIM NUMBER TO WORK (RTW) DATE RTW QUALIFIER RTW WITH RESTRICTIONS RELEASED RTW WITH RESTRICTIONS NUMBER OF DEPENDENTS DEATH DEPENDENT/ DATE OF MAXIMUM MEDICAL IMPROVEMENT PAYEE RELATIONSHIP WIDOW WIDOWER CHILDREN SIBLINGS PARENTS OTHER BODY PART PERCENT BODY PART PERCENT BODY PART PERCENT PERMANENT IMPAIRMENT EMPLOYER NAME FEIN INSURED REPORT NUMBER WAGE WAGE PERIOD AVERAGE WEEKLY WAGE NUMBER OF DAYS WORKED PER WEEK SALARY CONTINUED IN LIEU OF COMP? WEEKLY BI-WEEKLY YES NO MONTHLY SEMI-MONTHLY PAYMENTS PAID FROM PAID THROUGH # WEEKS # DAYS WEEKLY PAYMENT AMOUNT PAYMENT TYPE (MM/DD/YYYY) (MM/DD/YYYY) PAID PAID AMOUNT PAID TO DATE BENEFIT ADJUSTMENTS BENEFIT ADJUSTMENTS WEEKLY AMOUNT WEEKLY AMOUNT BENEFIT ADJUSTMENT TYPE (+ OR -) START DATE BENEFIT ADJUSTMENT TYPE (+ OR -) START DATE PAID-TO-DATE PAID-TO-DATE PAID TO DATE TYPE PAID TO DATE AMOUNT PAID TO DATE TYPE PAID TO DATE AMOUNT CLAIM ADMINISTRATION INSURER NAME FEIN OPEN REOPENED CLAIM STATUS CLOSED REOPENED/CLOSED THIRD PARTY ADMINISTRATOR NAME FEIN MEDICAL NOTIFICATION ONLY BECAME CLAIM ONLY LOST TIME TYPE INDEMNITY BECAME MED ONLY TRANSFER CLAIM ADMINISTRATOR CLAIM NUMBER WITHOUT LIABILITY AGREEMENT TO COMPENSATE WITH LIABILITY CLAIM ADMINISTRATOR ADDRESS LATE REASON PHONE # DATE PREPARED CITY STATE ZIP CODE FORM PREPARERS NAME PREPARERS PHONE <<<<<<<<<********>>>>>>>>>>>>> 2 General Instructions Items in bold are mandatory fields. Subsequent Report of Injury (SROI) without this information will be returned. ItemDefinitions Employee Namethe injured workers legally recognized name. Social Security Numbera number assigned by the Social Security Administration used to identify the employee. Date of Injurydate on which the accident occurred. Report Effective Date The date the payment which causes the form to be filed was made. Jurisdictionthe governing body or territory whose statutes apply (NE). Date Disability Beganthe first day on which the employee originally lost time from work due to the occupational injury or disease or as otherwise defined by the jurisdiction. Pre-Existing Disabilityidentifies the existence of a disability that existed prior to the injury. Date of Representationthe date the claim administrator became aware that the claimant had secured legal representation. Date of Deaththe date the injured worker died. Report PurposeThe MTC (maintenance type code) that corresponds to the reason the form is being filed. Released/Returned to Work (RTW) Datethe date, following the most recent disability period, on which the employee actually returned to work, or was released to return to work, as identified by the return to work qualifier. Released/RTW Qualifiera code identifying the employees return to work status, with or without physical restrictions. Agency Claim Numberthe number assigned by the Nebraska Workers Compensation Court to identify a specific claim. Number of Dependentsthe number of dependents as defined by the Nebraska Workers Compensation Act. Death Dependent/Payee Relationshipthe relationship of the dependent(s)/payee(s) to the deceased employee; to which relationship and benefit entitlement may be determined by an adjudicators decision for distribution of the death benefit. Date of Maximum Medical Improvementthe date after which further recovery from or lasting improvement to an injury or disease can no longer be anticipated based upon reasonable medical probability. Permanent Impairment Body Part Codea code referencing the part(s) of body permanently impaired. Permanent Impairment Percentagereport the amount of part(s) of body or functional abnormality or loss which results from the injury and exists after the date of maximum medical improvements. Employer Namethe name of the business entity of the insured where the employee was employed at the time of the injury. Employer FEINthe FEIN of the employer where the employee was employed at the time of the injury. Insured Report Numbera number used by the insured to identify a specific claim.Wage Wage Perioda code indicating the time period during which the wage was earned. Average Weekly Wagethe average wage of the employee at the time of injury as calculated by the claims administrator or jurisdictional authority for the wage period. Number of Days Worked Per Weekthe number of the employees regularly scheduled work days per week. Salary Continued In Lieu of Compthe employer has paid or is paying the employees salary in lieu of compensation during an absence caused by a work-related injury.Payments Payment Typea code that identifies the payment being made. Payment From Datethe first start date of a benefit period for which benefits were paid. Payment Through Datethe last date of a benefit period for which benefits were paid. Payment Weeks Paidthe number of whole weeks for a specific payment code. Payment Days Paidthe number of days paid for a specific payment code. Payment Weekly Amountthe net weekly rate for the payment code being paid. Payment Paid to Datethe cumulative amount paid for the payment code being paid.Benefit Adjustments Benefit Adjustment Type DO NOT USE. Reserved for future use. Benefit Adjustment Weekly Amount DO NOT USE. Reserved for future use. Benefit Adjustment Start Date DO NOT USE. Reserved for future use.Paid-To-Date Paid to Date Typea code that identifies the type of paid to date/reduced earnings/recoveries made. Paid to Date Amountthe amount defined by the paid to date/reduced earnings/recoveries code.Claim Administrator Insurer Namethe name of the insurer or self insured assuming the employers financial responsibility for workers compensation claim(s). Insurer FEINinsurers Federal Employers Identification Number. Third Party Administrator Namethe name of the Third Party Administrator contracted to adjust the claim on behalf of the carrier or self insured. Third Party Administrator FEINthe Federal Employers Identification Number of the third party administratoruster, contracted to adjust the claim on behalf of the insurer or selfs independent adj insured. Claim Administrator Claim Numberidentifies
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