Arizona
Arizona Employer Resource Guide
- Cover Sheet and Welcome Letter
- Table of Contents
- Instructions for Posters
- Notice to Employees: Arizona Workers’ 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 2212 - 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
- 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
California
California Employer Resource Guide
- 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
- 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
Connecticut
Connecticut Employer Resource Guide
- 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
Delaware
Delaware Employer Resource Guide
- Cover Sheet and Welcome Letter
- Table of Contents
- Instructions for Posters
- 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)
- Instructions for Informational Documents
- 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
- Company Contacts Verification
- Instructions for State-Specific Forms & Documents
- Executive Officers/LLC Exclusion Agreement
- Copy Request Form
Georgia
Georgia Employer Resource Guide
- Cover Sheet and Welcome Letter
- Table of Contents
- Instructions for Posters
- 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
- WC-6 - 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)
- 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
- 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
- Company Contacts Verification
- Instructions for State-Specific Forms & Documents
- WC-10 - Notice of Election or Rejection of Workers' Compensation Coverage
Illinois
Illinois Employer Resource Guide
- Cover Sheet and Welcome Letter
- Table of Contents
- Instructions for Posters
- 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
- Company Contacts Verification
Indiana
Indiana Employer Resource Guide
- Cover Sheet and Welcome Letter
- Table of Contents
- Instructions for Posters
- 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
- Company Contacts Verification
Iowa
Iowa Employer Resource Guide
- Cover Sheet and Welcome Letter
- Table of Contents
- Instructions for Posters
- 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
- Company Contacts Verification
Maryland
Maryland Employer Resource Guide
- Cover Sheet and Welcome Letter
- Table of Contents
- Instructions for Posters
- 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
- Claim Process Diagram
- 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
- Company Contacts Verification
- 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
- IC-03 - Joint Election Form
- IC-16 - Exclusion Form
Missouri
Missouri Employer Resource Guide
- Cover Sheet and Welcome Letter
- Table of Contents
- Instructions for Posters
- 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
- Company Contacts Verification
Nebraska
Nebraska Employer Resource Guide
- Cover Sheet and Welcome Letter
- Table of Contents
- Instructions for Posters
- 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
- Company Contacts Verification
Nevada
Nevada Employer Resource Guide
- Cover Sheet and Welcome Letter
- Table of Contents
- Instructions for Posters
- D-1 - Informational Poster
- 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
- 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
- D-25 - Affirmation of Compliance with Mandatory Industrial Insurance Requirements
- D-43 - Employee’s Election to Reject Coverage and Election to Waive the Rejection of Coverage for Excluded Persons
- D-44 - Election of Coverage by Employer; Employer Withdrawal of Election of Coverage
- D-23 – Employee’s Declaration of Election to Report Tips
New Jersey
New Jersey Employer Resource Guide
- Cover Sheet and Welcome Letter
- Table of Contents
- Instructions for Posters
- 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
- 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
- Company Contacts Verification
New York
New York Employer Resource Guide
- Cover Sheet and Welcome Letter
- Table of Contents
- Instructions for Posters
- 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
- Company Contacts Verification
- Instructions for State-Specific Forms & Documents
- C-105.32 - Notice of Election to Bring Partners, Members or Self-Employed Persons Under the Coverage of the New York State Workers' Compensation Law
- C-105.51 - Notice of Election to Exclude Sole Shareholder Officer or Two Executive Officers of the Corporation from Compensation Coverage
- C-105.55 - Revocation of Election to Exclude Sole Shareholder or Two Executive Officers from Compensation Coverage
North Carolina
North Carolina Employer Resource Guide
- Cover Sheet and Welcome Letter
- Table of Contents
- Instructions for Posters
- 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 19 - Employer's Report of Employee's Injury or Occupational Disease to the Industrial Commission
- 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
- Company Contacts Verification
Pennsylvania
Pennsylvania Employer Resource Guide
- Cover Sheet and Welcome Letter
- Table of Contents
- Instructions for Posters
- 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
- Company Contacts Verification
- Instructions for State-Specific Forms & Documents
- Workers’ Compensation Information Handout (Versión en Español)
- Employee Acknowledgement Form (Versión en Español)
South Carolina
South Carolina Employer Resource Guide
- 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)
- 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
Wisconsin
Wisconsin Employer Resource Guide
- Cover Sheet and Welcome Letter
- Table of Contents
- Instructions for Posters
- 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
- Company Contacts Verification