Cover Sheet and Welcome Letter
Table of Contents
Instructions for Posters
C-105 – Notice of Compliance – Workers’ Compensation Law
C-105.1 – Notice to be Posted for Automotive or Horse- Drawn Vehicles
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Report Forms
C-2F – Employer’s First Report of Work-Related Injury/Illness
C-240 – Employers Statement of Wages
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-430S – Statement of Rights (Versión en Español)
Claimant Quick Start Guide (Versión en Español)
C-3.3 – Limited Release of Health Information (Versión en Español)
C-3 – Employee Claim (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
Your Responsibilities as Employer – Reporting Injury/Illness
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
C-105.32 – Notice of Election to Bring Partners, Members or Self-Employed Persons Under the Coverage of the New York State Workers’ Compensation Law
C-105.51 – Notice of Election to Exclude Sole Shareholder Officer or Two Executive Officers of the Corporation from Compensation Coverage
C-105.55 – Revocation of Election to Exclude Sole Shareholder or Two Executive Officers from Compensation Coverage
