Cover Sheet and Welcome Letter
Table of Contents
Instructions for Posters
Notice to Employees Poster (Versión en Español)
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
Form IA-1 – First Report of Injury
Form 127 – Average Weekly Wage Computation Schedule
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 – Request for Ownership Information
Company Contacts Verification
Instructions for State-Specific Forms & Documents
Form 153 – Affidavit of Exemption for Certain Corporate Officers or Directors
