Cover Sheet and Welcome Letter
Table of Contents
Instructions for Posters
Worker’s Compensation Notice (Versión en Español)
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
WCB Form 34401 – IN Work Comp First Report of Injury, 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)
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
Notice of Electronic Form 36097 – Notice for Worker’s Compensation and Occupational Diseases Coverage
