Cover Sheet and Welcome Letter
Table of Contents
Instructions for Posters
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
Injured Workers First Fill Prescription Form (Versión en Español)
Form 307 – Medical Treatment Provider List
Form 308 – Authorization to Disclose, Release & Use Protected Health Information – Non-PTD Claims
Form 308 – Authorization to Disclose, Release & Use Protected Health Information – PTD Claims
Consent & Authorization for Release of Information (Versión en Español)
Request for Medical History (Versión en Español)
Direct Deposit Authorization Form (Versión en Español)
Form 100 – Injured Workers’ Rights and Responsibilities (Versión en Español)
Instructions for Informational Documents
Omaha National Contact Information
Reduce Your Workers Compensation Costs
Employer’s Guide to Workers’ Compensation
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
Corporate Office Exclusion Form
