Cover Sheet and Welcome Letter
Table of Contents
Instructions for Posters
Form 2 – Employer’s Notice of Being Subject to the Act
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
Form 12A – First Report of Injury or Illness
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)
Form 65 – Occupational Disease Waiver
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)
Authorization for Release of Claims Information
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
Form 5 – Corporate Officer Notice to Reject
Form 38 – Employer’s Withdrawal of Election to Adopt the South Carolina Workers’ Compensation Act
