Cover Sheet and Welcome Letter
Table of Contents
Instructions for Posters
Workers’ Compensation Posting Notice (Versión en Español)
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
IA-1 – First Report of Injury
Request for Wage Information (Versión en Español)
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)
Form 106 – Medical Waiver and Consent Form
Form 105 – Plaintiff’s Chronological Medical History
Consent and Authorization for Release of Information Form (Versión en Español)
Request for Medical History Form (Versión en Español)
Form 104 – Plaintiff’s Employment History
Form – Release and Consent to Disclosure
Form 114 – Request for Payment of Services or Reimbursement
Direct Deposit Authorization Form (Versión en Español)
Instructions for Informational Documents
Omaha National Contact Information
Reduce Your Workers Compensation Costs
Instructions for General Forms
Form ERM-14 – Confidential Request for Ownership Information
Company Contacts Verification
Instructions for State-Specific Forms & Documents
Form 4 – Employee’s Notice of Rejection of Workers’ Compensation Act
Form 5 – Written Notice of Withdrawal of Form 4 Rejection
