Cover Sheet and Welcome Letter
Table of Contents
Instructions for Posters
Notice to Employees
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
Form FRI – Employer’s First Report of Occupational Injury or Illness
Incident Investigation Report (Versión en Español)
Supervisor’s Report of Employee Incident (Versión en Español)
Witness Statement of Injury or Incident (Versión en Español)
Instructions for Injured Worker Handouts
Injured Workers First Fill Prescription Form (Versión en Español)
Authorization to Obtain and/or Disclose Health Information
Form 1A – Filing Status and Exemption
Consent and Authorization for Release of Information Form (Versión en Español)
Request for Medical History Form (Versión en Español)
Direct Deposit Authorization Form (Versión en Español)
Instructions for Informational Documents
Omaha National Contact Information
Reduce Your Workers Compensation Costs
Instructions for General Forms
Request for Subrogation Waiver
Form ERM-14 – Confidential Request for Ownership Information
Company Contacts Verification
Instructions for State-Specific Forms & Documents
Directions for Forms 6B, 6B-1, and 75
Form 6B – Coverage Election by Employee – Officer of Corporation or Member of LLC
Form 6B-1 – Coverage Election by Employees – Members of Partnership
Form 75 – Coverage Election by Sole Proprietor
