Cover Sheet and Welcome Letter
Table of Contents
Instructions for Posters
Workers’ Compensation Compliance Poster (Versión en Español)
Workers’ Compensation Fraud Poster
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Report Forms
LWC-WC IA-1 – Employers First Report of Injury
LWC-WC-1025-ER – Employer Certificate of Compliance
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
LWC-WC 1121 – Physician Choice Form (Versión en Español)
LWC-WC-1025-EE – Employee Certificate of Compliance (Versión en Español)
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)
Mileage Reimbursement Log
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
