Cover Sheet and Welcome Letter
Table of Contents
Instructions for Posters
D-1 – Informational Poster
D-22 – Notice to Employees – Tip Information
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
C-3 – Employer’s Report of Industrial Injury or Occupational Disease
D-8 – Employer’s Wage Verification Form
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)
C-1 – Notice of Injury or Occupational Disease
D-2 – Brief Description of Rights and Benefits
D-53 – Alternative Choice of Physician or Chiropractor
D-36 – Request for Additional Medical Information and Medical Release
Consent and Authorization for Release of Information Form (Versión en Español)
Request for Medical History 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
D-25 – Affirmation of Compliance with Mandatory Industrial Insurance Requirements
D-43 – Employee’s Election to Reject Coverage and Election to Waive the Rejection of Coverage for Excluded Persons
D-44 – Election of Coverage by Employer; Employer Withdrawal of Election of Coverage
D-23 – Employee’s Declaration of Election to Report Tips
