Cover Sheet and Welcome Letter
Table of Contents
Instructions for Posters
Notice to Employees: Arizona Worker’s Compensation Law
Notice to Employees: Work Exposure to Bodily Fluids (HIV, AIDS, Hepatitis C), (Versión en Español)
Notice to Employees: Work Exposure to MRSA, Spinal Meningitis, or Tuberculosis (TB)
Minimum Wage Poster, (Versión en Español)
Earned Paid Sick Time Poster, (Versión en Español)
Employee Safety and Health Protection Poster, (Versión en Español)
Fraud Prevention Poster, (Versión en Español)
Instructions for Injury Report Forms
ICA 04-0101 – Employer’s Report of Industrial Injury
ICA 2210 – Serious Event Reporting 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)
ICA 0407 – Workers’ Report of Injury, (Versión en Español)
ICA 0124 – Report of Significant Work Exposure to Bodily Fluids or Other Infectious Material
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
Significant Exposure Under the Arizona Workers’ Compensation Act
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
ICA 0113 – Employee’s Notice of Rejection of Terms of the Arizona Workers’ Compensation Law
ICA 0114 – Employee’s Notice to Revoke Rejection of Terms of the Arizona Workers’ Compensation Law
Cover Sheet and Welcome Letter
Table of Contents
Instructions for Posters
DWC-7 – Notice to Employees – Injuries Caused by Work (Versión en Español)
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Report Forms
DLSR-5020 – Employer’s Report of Occupational Injury or Illness
DIA-510 – Notice of Employee Death
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)
DWC-1 – Claim Form & Notice of Potential Eligibility (Versión en Español)
Employee Medical Provider Network Notice (Versión en Español)
Notice to Victims of Workplace Crimes (Versión en Español)
Employee Acknowledgement Form – Part Two (Versión en Español)
Consent and Authorization for Release of Information Form (Versión en Español)
Request for Medical History Form (Versión en Español)
Instructions for Informational Documents (Versión en Español)
Omaha National Contact Information
Medical Provider Network (MPN) Information for Employers
Reduce Your Workers Compensation Costs
Instructions for General Forms
Request for Subrogation Waiver
Notice of Ownership Change
Company Contacts Verification
Instructions for State-Specific Forms & Documents
DWC Time of Hire Pamphlet (Versión en Español)
Employee Acknowledgement Form – Part One (Versión en Español)
Utilization Review Plan
Cover Sheet and Welcome Letter
Table of Contents
Instructions for Posters
Notice to Employees
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
Form FRI – Employer’s First Report of Occupational 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)
Authorization for the Release of Medical Records by Provider for Administering a CT WC Claim for Benefits
Form 1A – Filing Status and Exemption
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
Form 6B – Coverage Election by Employee – Officer of Corporation or Member of LLC
Form 6B-1 – Coverage Election by Employees – Members of Partnership
Form 75 – Coverage Election by Sole Proprietor
Cover Sheet and Welcome Letter
Workers Compensation Poster (Versión en Español)
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
First Report of Occupational Injury or Disease
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)
Direct Deposit Authorization Form (Versión en Español)
Instructions for Informational Documents (Versión en Español)
Omaha National Contact Information
Reduce Your Workers Compensation Costs
Instructions for General Forms
Request for Subrogation Waiver
NCCI ERM-14 – Confidential Request for Ownership Information
Instructions for State-Specific Forms & Documents
Cover Sheet and Welcome Letter
Workers Compensation Poster (Versión en Español)
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
First Report of Occupational Injury or Disease
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)
Direct Deposit Authorization Form (Versión en Español)
Important Worker’s Compensation Information for Florida’s Workers (Versión en Español)
Employee Notification Letter (Versión en Español)
Instructions for Informational Documents
Omaha National Contact Information
Reduce Your Workers’ Compensation Costs
Important Workers’ Compensation Information for Florida’s Employers (Versión en Español)
Instructions for General Forms
Request for Subrogation Waiver
NCCI ERM-14 – Confidential Request for Ownership Information
Instructions for State-Specific Forms & Documents
Cover Sheet and Welcome Letter
WC-BOR – Bill of Rights for the Injured Worker (Versión en Español)
WC-P1 – Panel of Physicians (Versión en Español)
WC-P3 – WC/MCO Panel (Versión en Español)
Stop Workers’ Compensation Fraud and Insurance Non-Compliance (Versión en Español)
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
WC-1 – Employer’s First Report of Injury
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)
Panel Acknowledgement and Physician Selection (Versión en Español)
WC-207 – Authorization and Consent to Release Information
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
Workers Compensation Resource for Employers
Provider Panel Information for Employers
Best Practices: Role of the Employer
Best Practices: Early Return-to-Work Program
Instructions for General Forms
Request for Subrogation Waiver
Form ERM-14 – Confidential Request for Ownership Information
Instructions for State-Specific Forms & Documents
WC-10 – Notice of Election or Rejection of Workers’ Compensation Coverage
Cover Sheet and Welcome Letter
ICPN – Workplace Notice (Versión en Español)
IDOI Workers’ Compensation Fraud Poster (Versión en Español)
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
IC-45 – Employer’s First Report of Injury
IC-85 – Employer’s Supplementary Report of Injury
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)
Instructions for Informational Documents
Omaha National Contact Information
Reduce Your Workers Compensation Costs
Handbook on Workers’ Compensation and Occupational Diseases (Versión en Español)
Instructions for General Forms
Request for Subrogation Waiver
Form ERM-14 – Confidential Request for Ownership Information
Cover Sheet and Welcome Letter
Worker’s Compensation Notice (Versión en Español)
WCB Form 36097 – Notice for Workers’ Compensation and Occupational Diseases Coverage
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
WCB Form 34401 – IN Work Comp First Report of Injury, 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)
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
Cover Sheet and Welcome Letter
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
DWC Form 14-0001 – 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)
DWC Form 14-0043 – Authorization to Release Information Regarding Claimants Seeking WC Benefits
DWC Form 14-0196 – Authorization for the Iowa DWC to Release Information
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
Cover Sheet and Welcome Letter
K-WC-40A – Workers Compensation Rights and Responsibilities
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
Form IA-1 – First Report of Injury
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
K-WC 27-A – Information for Injured Employees (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)
K-WC 25 – Workers Compensation Information for Kansas Employers and Employees (Versión en Español)
Direct Deposit Authorization Form (Versión en Español)
Instructions for Informational Documents
Omaha National Contact Information
Reduce Your Workers Compensation Costs
K-WC 530 – Employee Notification Forms Available Online
K-WC 25 – Workers Compensation Information for Kansas Employers and Employees
Instructions for General Forms
Request for Subrogation Waiver
Form ERM-14 – Confidential Request for Ownership Information
Instructions for State-Specific Forms & Documents
K-WC 50 – Election of Employee Not to Accept Coverage
K-WC 113 – Election of Individual to Come Under Act
K-WC 137 – Election of a Noncompensated Volunteer Officer, Director or Trustee
Affidavit of Exempt Status Under the Workers Compensation Act (Versión en Español)
Cover Sheet and Welcome Letter
Workers’ Compensation Posting Notice (Versión en Español)
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
Request for Wage Information (Versión en Español)
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 106 – Medical Waiver and Consent Form
Form 105 – Plaintiff’s Chronological Medical History
Consent and Authorization for Release of Information Form (Versión en Español)
Request for Medical History Form (Versión en Español)
Form 104 – Plaintiff’s Employment History
Form – Release and Consent to Disclosure
Form 114 – Request for Payment of Services or Reimbursement
Direct Deposit Authorization Form (Versión en Español)
Instructions for Informational Documents
Omaha National Contact Information
Reduce Your Workers Compensation Costs
Instructions for General Forms
Form ERM-14 – Confidential Request for Ownership Information
Instructions for State-Specific Forms & Documents
Form 4 – Employee’s Notice of Rejection of Workers’ Compensation Act
Cover Sheet and Welcome Letter
C-24 – Employer’s Posting Notice (Versión en Español)
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
IA-1 – Employer’s First Report of Injury
C-2 – Statement of Wage Information
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)
A-25R – Authorization for Disclosure of Health Information
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
C-98 – FAQs for Employers About Maryland Workers’ Compensation Law
Instructions for General Forms
Request for Subrogation Waiver
Form ERM-14 – Confidential Request for Ownership Information
Instructions for State-Specific Forms & Documents
C-15R – Inclusion Form for Sole Proprietors/Partners Election
H23R – Request for Employer Designee to Receive Notice of Employee Claims
Cover Sheet and Welcome Letter
DWC Form WC-106 – Workers’ Compensation Law – Roles and Responsibilities for Employers and Employees (Versión en Español)
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
DWC Form WC-1-EDI – Report of Injury
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)
DWC Form WC-280 – Report Your Workplace Injury, Occupational Disease, or Repetitive Trauma Injury
DWC Form WC-303 – Claimant Authorization to Disclose Worker’s Compensation Records
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
DWC Brochure WC-259 – Workers’ Compensation Requirements For the Missouri Construction Industry
Instructions for General Forms
Request for Subrogation Waiver
Form ERM-14 – Confidential Request for Ownership Information
Cover Sheet and Welcome Letter
Fraud Prevention Poster (Versión en Español)
Insurance Fraud Leaves a Paper Trail Poster
Insurance Fraud Makes Me Croak Poster
Instructions for Injury Reports
NWCC Form 1 – First Report of Occupational 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)
Choosing a Doctor for a Work-Related Injury – Rule 50 (Versión en Español)
NWCC Form 50 – Employees Choice or Change of Doctor (Versión en Español)
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
NE Workers’ Compensation Court Information Sheet – NE Workers’ Compensation (Versión en Español)
Instructions for General Forms
Request for Subrogation Waiver
Form ERM-14 – Confidential Request for Ownership Information
Cover Sheet and Welcome Letter
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
Workers Compensation Resource for Employers
Instructions for General Forms
Request for Subrogation Waiver
Form ERM-14 – Confidential Request for Ownership Information
Instructions for State-Specific Forms & Documents
D-25 – Affirmation of Compliance with Mandatory Industrial Insurance Requirements
D-44 – Election of Coverage by Employer; Employer Withdrawal of Election of Coverage
Cover Sheet and Welcome Letter
Form 16 NJ A – Posting Notice (Versión en Español)
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
Form IA-1 – 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 (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)
Instructions for Informational Documents
Omaha National Contact Information
Reduce Your Workers Compensation Costs
An Employer’s Guide to Workers’ Compensation in New Jersey
Instructions for General Forms
Form ERM-14 – Confidential Request for Ownership Information
Cover Sheet and Welcome Letter
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
Cover Sheet and Welcome Letter
Form 17 – Workers’ Compensation Notice to Injured Workers and Employers (Versión en Español)
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports (NC)
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)
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
Cover Sheet and Welcome Letter
LIBC-500 – Workers’ Compensation Insurance Posting (Versión en Español)
Employer Medical Provider Panel (Versión en Español)
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
IA-1 – 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)
LIBC-100 – Workers’ Compensation and the Injured Worker (Versión en Español)
Work Comp Information Handout (Versión en Español)
Employee Acknowledgement Form (Versión en Español)
Panel Acknowledgement and Physician Selection (Versión en Español)
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
Provider Panel Information for Employers
Instructions for General Forms
Request for Subrogation Waiver
NCCI Form ERM-14 – Confidential Request for Ownership Information
Instructions for State-Specific Forms & Documents
Workers’ Compensation Information Handout (Versión en Español)
Cover Sheet and Welcome Letter
Complete Omaha National SC Workers Compensation Resource for Employers – 4-10-2025
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
Direct Deposit Authorization Form (Versión en Español)
Authorization for Release of Claims Information
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)
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
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
Cover Sheet and Welcome Letter
LB-0922 – Tennessee Workers’ Compensation Insurance Posting Notice (Versión en Español)
Fraud Prevention Poster, (Versión en Español)
Instructions for Injury Reports
LB-0021 – C-20 – Employer’s First Report of Work Injury or Illness
LB-0384 – C-41 – Wage Statement
Incident Investigation Report Form (Versión en Español)
Supervisor’s Report of Employee Incident (Versión en Español)
Witness Statement of Employee Incident (Versión en Español)
Instructions for Injured Worker Handouts
LB-0382 – C-42 – Employee’s Choice of Physician – Medical Panel(Versión en Español)
LB-0379 – C-31 – Medical Waiver and Consent (Versión en Español)
Consent & Authorization for Release of Information (Versión en Español)
Request for Medical History (Versión en Español)
Injured Workers First Fill Prescription Form (Versión en Español)
LB-0030 – Combined I-10, I-11, I-12 – Notice of Waiver of Workers’ Compensation Benefits for Specific Medical Conditions (Versión en Español)
LB-0290 – Form I-13 – Notice of Withdrawal of a Previously Signed Waiver
Instructions for Informational Documents
Omaha National Contact Information
Reduce Your Workers Compensation Costs
Provider Panel Information for Employers
LB-3265 – Notice of Employer Rights and Responsibilities in a Workers’ Compensation Claim
Instructions for General Forms
Request for Subrogation Waiver
Form ERM-14 – Confidential Request for Ownership Information
Instructions for State-Specific Forms & Documents
LB-3271 – Request for Prior Work Injury Information
LB-0288 – I-7 – Notice of Corporate Officer’s Revocation of Exemption
LB-0228 – I-4 – Notice of Election (Sole Proprietor, Member of LLC, or Partner) (Versión en Español)
LB-0287 – I-5 – Notice of Withdrawal (Sole Proprietor, Member of LLC, or Partner) (Versión en Español)
LB-0301 – Combined I-15 & I-17 – General Contractor Acceptance – Termination of Coverage Agreement
Cover Sheet and Welcome Letter
Workers’ Compensation Notice (Versión en Español)
Fraud Prevention Poster, (Versión en Español)
Instructions for Injury Reports
Form 122 E – Employers First Report of Injury or Illness
Incident Investigation Report Form (Versión en Español)
Supervisor’s Report of Employee Incident (Versión en Español)
Witness Statement of Employee Incident (Versión en Español)
Instructions for Injured Worker Handouts
LB-0382 – C-42 – Employee’s Choice of Physician – Medical Panel(Versión en Español)
LB-0379 – C-31 – Medical Waiver and Consent (Versión en Español)
Consent & Authorization for Release of Information (Versión en Español)
Request for Medical History (Versión en Español)
Injured Workers First Fill Prescription Form (Versión en Español)
LB-0030 – Combined I-10, I-11, I-12 – Notice of Waiver of Workers’ Compensation Benefits for Specific Medical Conditions (Versión en Español)
LB-0290 – Form I-13 – Notice of Withdrawal of a Previously Signed Waiver
Instructions for Informational Documents
Omaha National Contact Information
Reduce Your Workers Compensation Costs
Provider Panel Information for Employers
LB-3265 – Notice of Employer Rights and Responsibilities in a Workers’ Compensation Claim
Instructions for General Forms
Request for Subrogation Waiver
Form ERM-14 – Confidential Request for Ownership Information
Instructions for State-Specific Forms & Documents
LB-3271 – Request for Prior Work Injury Information
LB-0288 – I-7 – Notice of Corporate Officer’s Revocation of Exemption
LB-0228 – I-4 – Notice of Election (Sole Proprietor, Member of LLC, or Partner) (Versión en Español)
LB-0287 – I-5 – Notice of Withdrawal (Sole Proprietor, Member of LLC, or Partner) (Versión en Español)
LB-0301 – Combined I-15 & I-17 – General Contractor Acceptance – Termination of Coverage Agreement
Cover Sheet and Welcome Letter
Notice to Employees – Workers Compensation Coverage (Versión en Español)
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
OIC-WC-2 – Employers’ Report of Occupational Injury or Disease
Incident Investigation Report Form (Versión en Español)
Supervisor’s Report of Employee Incident (Versión en Español)
Witness Statement of Employee Incident (Versión en Español)
Instructions for Injured Worker Handouts
OIC-WC-1 – Employees’ and Physicians’ Report of Occupational Injury or Disease
Injured Workers First Fill Prescription Form (Versión en Español)
Consent & Authorization for Release of Information (Versión en Español)
Request for Medical History (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
Form ERM-14 – Confidential Request for Ownership Information
Instructions for State-Specific Forms & Documents
WVWC-RF01 – Notice of Election or Rejection of Workers’ Compensation Coverage
Cover Sheet and Welcome Letter
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
DWD-DWC Form WKC-12-E – Employer’s First Report of Injury or Disease (Versión en Español)
DWD-DWC Form WKC-13-A-E – Wage Information Supplement
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)
DWD-DWC Form WKC-9488-E – Voluntary and Informed Consent for Disclosure of Health Care Information (Versión en Español)
DWD-DWC Form WKC-12698-E – Statement of Self-Restriction to Part-Time Work (Versión en Español)
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
DWD-DWC Brochure WKC-7317-P – Wisconsin Worker’s Compensation Law – Employer Facts
Instructions for General Forms
Request for Subrogation Waiver
Form ERM-14 – Confidential Request for Ownership Information
