Cover Sheet and Welcome Letter
Table of Contents
Instructions for Posters
DWC-8 – Workers’ Compensation Act Poster (Versión en Español)
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
DWC-01 – Employer’s First Report of Alleged Occupational Injury, Disease or Fatality
Instructions for Form DWC-03F and DWC-03P
DWC-03F – Full-time Wage Statement
DWC-03P – Part-time Wage Statement
Instructions for Form DWC-03S
DWC-03S – Seasonal Wage Statement
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)
DWC-EB1 – Agreement for Electronic Payment of Benefits
DWC-EB2 – Rescission of Agreement for Electronic Payment of Benefits
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
DWC-11 – Notice of Claim of Common Law Rights
DWC-11R – Rescind Notice of Claim of Common Law Rights
Notice to Job Applicants – Notice of Workers Compensation Coverage (Versión en Español)
