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Employer Business Name *

Employer Contact Name *

Injured Employee's First Name *

Injured Employee's Last Name *

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Employer Contact Phone Number

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

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Date of Injury *

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How much work has the employee missed?

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Form 19 – Employer’s Report of Employee’s Injury or Occupational Disease to the Industrial Commission (NC)

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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.