Cover Sheet and Welcome Letter
Table of Contents
Instructions for Posters
Form 17 – Workers’ Compensation Notice to Injured Workers and Employers (Versión en Español)
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
Form 19 – Employer’s Report of Employee’s Injury or Occupational Disease to the Industrial Commission
Form 22 – Statement of Days Worked and Earnings of Injured Employee
Form 29 – Supplemental Report for Fatal Accidents
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
Form 18 – Notice of Accident to Employer and Claim of Employee, Representative, or Dependent (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)
Instructions for Informational Documents
Omaha National Contact Information
Reduce Your Workers Compensation Costs
Instructions for General Forms
Request for Subrogation Waiver
NCCI Form ERM-14 – Confidential Request for Ownership Information
Company Contacts Verification
