Cover Sheet and Welcome Letter
Table of Contents
Instructions for Posters
Form A-16 – Notice of Coverage (AKA Mississippi Workers’ Compensation Poster) (Versión en Español)
Notice Concerning Changes to WC Law Effective 07-01-2012 (AKA Notice of Senate Bill 2576)
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
Form B-3 – Employer’s First Report of Injury or Occupational Disease
Form R-1 – Early Notification of Severe Injury
Incident Investigation Report Form (Versión en Español)
Supervisor’s Report of Employee Incident (Versión en Español)
Witness Statement of Employee Incident (Versión en Español)
Instructions for Injured Worker Handouts
Notice of Right to Choose and Doctor Selection (Versión en Español)
Injured Workers First Fill Prescription Form (Versión en Español)
Consent & Authorization for Release of Information (Versión en Español)
Request for Medical History (Versión en Español)
Mileage Reimbursement 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
