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Employer Business Name *

Employer Contact Name *

Injured Employee's First Name *

Injured Employee's Last Name *

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Employer Contact Phone Number

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Injured Employee's Phone Number (if unknown check box)

Injured Employee's Phone Number

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Date of Injury *

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Accident State

Injured Worker's Date of Birth

How much work has the employee missed?

Injured Worker's Social Security Number

Injured Worker's Email

Injured Worker's Street Address

Injured Worker's City Address

Mailing State

Injured Worker's Zip Code

Policy Number

Additional Information (Body parts injured, name and location of medical treatment facility, work status…)

Website

Employer Payroll Videos
Employee Payroll Videos
Payroll Documents

How to Batch Enter Employee Hours – Standard

How to Hire an Employee

How to Update Employee Information

How to Terminate an Employee

How to Make Changes to Your Account

How to View Your Pay Statements

How to Add a New W-4 Withholding Form

How to Manage Your Timesheet and Request Time Off

How to Set-up Direct Deposit to Your Checking Account

How to View and Download a W-2

Payroll Documents

CA EDD Form DE-4 – Employees Withholding Allowance Certificate – 12-2022
CA EDD Form DE-4 – Employees Withholding Allowance Certificate – 12-2022 (Versión en Español)
IRS Form W-4 – Employee’s Withholding Certificate – 2023
Omaha National – Holiday Payroll Processing Schedule
Omaha National Form – Employee ACH Authorization
Omaha National Form – Employee Acknowledgements
Omaha National Form – Payroll Deduction Authorization

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Omaha National Underwriters, LLC is an MGA licensed to do business in several states including California. CA License NO. 078229.
Coverage is provided by Omaha National Insurance Company, Preferred Professional Insurance Company, and/or Palomar Specialty Insurance Company. Coverage may not be available in all states.

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Payroll Services

Report An Injury

Required Information

Optional Information

Employer Payroll Videos

How to Batch Enter Employee Hours – Standard

How to Hire an Employee

How to Update Employee Information

How to Terminate an Employee

Employee Payroll Videos

How to Make Changes to Your Account

How to View Your Pay Statements

How to Add a New W-4 Withholding Form

How to Manage Your Timesheet and Request Time Off

How to Set-up Direct Deposit to Your Checking Account

How to View and Download a W-2

Payroll Documents