Report an Injury
Find a Doctor
Login

Agents/Brokers
Employers
Injured Workers
Resources
Careers
Contact
Report an Injury
Find a Doctor
Login

Logins

Payroll Services Self-Reporting Payroll

Payroll Services

Problems logging in?
Please only enter your company code and click "Forgot Password?".

Report An Injury

Required Information

Employer Business Name *

Employer Contact Name *

Injured Employee's First Name *

Injured Employee's Last Name *

Employer Contact Phone Number (if unknown check box)

Employer Contact Phone Number

unknown

Injured Employee's Phone Number (if unknown check box)

Injured Employee's Phone Number

unknown

Date of Injury *

Optional Information

Please feel free to provide this detail, but don't delay reporting the claim to gather this information.

Employer's Email

We will automatically send you a claim number within 1 business day.

Accident State

Injured Worker's Date of Birth

How much work has the employee missed?

Injured Worker's Social Security Number

Injured Worker's Email

Injured Worker's Street Address

Injured Worker's City Address

Mailing State

Injured Worker's Zip Code

Policy Number

Additional Information (Body parts injured, name and location of medical treatment facility, work status…)

Comment

Authorization for the Release of Medical Records by Provider for Administering a CT WC Claim for Benefits (CT)

OLDEST

NEWEST

Search for:

Omaha National Appoints Joan Klucarich as Chief Actuary
AM Best Assigns Credit Ratings to Omaha National Casualty Company; Affirms Credit Ratings of Omaha National Insurance Company
Omaha National Acquires California Domiciled Insurance Company
Omaha National Appoints Dale Mackel Chief Financial Officer
Omaha National Surpasses $150 Million in In-Force Premium

Services

Agents/Brokers
Employers
Injured Workers

Connect

Careers
News
Contact

Logins

Payroll Services
Self-Reporting Payroll
Client Resources
Medical Providers

Omaha National Underwriters, LLC is an MGA licensed to do business in several states including California. CA License NO. 078229.
Coverage is provided by Omaha National Insurance Company, Preferred Professional Insurance Company, and/or Palomar Specialty Insurance Company. Coverage may not be available in all states.