Nebraska Required Postings and Forms
Please print and post the following notices in a conspicuous location frequented by employees such as the break room, lunch room or time clock. If you have multiple business locations be sure to post the notices at each location.
The following forms need to be completed and submitted to appropriate parties when a work-related injury occurs:
- NWCC Form 1 First Report of Injury (FROI). As soon as you have been notified of a work-related injury, please fill out this form and submit it to EMPLOYERS. This form must be completed within 10 days from notice of a work-related injury. Fatalities must be reported within 24 hours. Please use this form to notify EMPLOYERS of every work-related injury or disease suffered by an employee, regardless of severity.
- Form 50, Choice of Doctor (English and Spanish). As soon as you have been notified of a work-related injury, you must provide this form to your injured employee. The form must be completed and signed by the injured employee and returned to the employee’s supervisor/ manager as soon as possible after the accident.
- Wage Statement. This form enables us to calculate the correct compensation that may be owed to your injured employee. Please complete the form and submit it to EMPLOYERS within five days after your knowledge of any work-related injury or occupational disease that has caused your employee to be disabled for more than the Nebraska waiting period of seven scheduled work days.
- First Fill Form. This form provides your employees with basic information about our Pharmacy Benefit Program, including such things as the phone number to call to locate a First Fill participating pharmacy. When your employee becomes injured, please print and complete this form and provide it to your injured employee. Your employee will need to provide this completed form along with the prescription for his/her work-related injury or occupational disease to the pharmacist. Using this form will help enable quick authorization for your employee’s initial medication and ensure that the initial prescription is provided at no cost to the injured employee.
- Accident Investigation Report. This basic accident form should be completed by the employee’s supervisor/manager as soon as possible after the accident. Please send the report to the following EMPLOYERS address as soon as it has been completed by the supervisor/manager: EMPLOYERS Claim Department, P.O. Box 32036, Lakeland, FL 33802-2036. You should also keep a copy on file for your records.
More Nebraska Workers’ Comp Resources
- Off-Site Transitional Duty Program – Helping Your Injured Employees Get Back to Work. A successful transition back to work relies on the collaborative efforts of the manager/supervisor, the injured employee and their adjuster. As a manager/supervisor, learn what you can do to help facilitate a successful return to work.