Fill and Sign the First Report of Alleged Occupational Injury or Illness Aigcom Form

NWCC FORM 4 REVISED 06/2006 CLAIM STATUS CLAIM TYPE AGREEMENT TO COMPENSATE WAGE PERIOD PERMANENT IMPAIRMENT Nebraska Workers’ Compensation Court—SUBSEQUENT REPORT EMPLOYEE NAME (Last, First, Middle) SOCIAL SECURITY NUMBER DATE OF INJURY REPORT EFFECTIVE DATE JURISDICTION DATE DISABILITY BEGAN PRE-EXISTING ‰ YES DATE 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 EMPLOYER NAME FEIN INSURED REPORT NUMBER WAGE AVERAGE WEEKLY WAGE NUMBER OF DAYS WORKED PER WEEK SALARY CONTINUED I N LIEU OF COMP? ‰ YES ‰ NO 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 TYPEPAID TO DATE AMOUNT CLAIM ADMINISTRATION INSURER NAME FEINOPEN‰ REOPENED ‰ CLOSED ‰ REOPENED/CLOSED ‰ THIRD PARTY ADMINISTRATOR NAME FEINMEDICAL‰ NOTIFICATION ONLY ‰BECAME‰ ONLY LOST TIME INDEMNITY ‰ BECAME MED ONLY ‰TRANSFER‰ CLAIM ADMINISTRATOR CLAIM NUMBER WITHOUT LIABILITY‰ WITH LIABILITY ‰ CLAIM ADMINISTRATOR ADDRESS LATE REASON DATE PREPARED CITY STATE ZIP CODE FORM PREPARER’S NAME PREPARER’S PHONE ‰ WEEKLY ‰ BI-WEEKLY ‰ MONTHLY ‰ SEMI-MONTHLY PHONE # General Instructions Items in bold are mandatory fields. Subsequent Report of Injury ( SROI) without this information will be returned. Item—Definitions