Marcia Hultman

Cabinet Secretary

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Workers' Compensation

Forms

Many forms used in the Workers' Compensation program are available from this page, organized into the following categories. Unless otherwise noted, the forms are provided in Adobe PDF format.

Independent Contract Forms

Injury Forms

Self-Insurance Forms

Case Management and Dispute Resolution Forms

Application for Scholarship for Survivor Children

Independent Contractor Forms

Independent Contractor Affidavit of Exempt Status and Fact Sheet

Independent Contractor Verification Form (for truck owner-operators only)

Injury Forms

First Report of Injury

Petition for Hearing

Complete the Petition for Hearing form online, then print for mailing.

Print the Petition for Hearing form, then complete and mail it.

Petition for Hearing on Medical Benefits

Mediation Request

Complete the Mediation Request online, then print for mailing. Or, if you prefer, you can print the form using the same link, then complete and mail it in.

Request for Extension of Time (Complete and submit online using the First Report of Injury Management System after reading important instructions.)

Monthly Payment Report (Form 107)

Complete the Monthly Payment Report online, then print for mailing.

Complete and submit online using the First Report of Injury Management System after reading important instructions.

Calculation of Compensation (Form 110)

Memorandum of Payment for Permanent Partial Disability (Form 111)

Memorandum of Payment for Rehabilitation (Form 113)

Statement of Weekly Earnings (print only)

Hand Diagram (Form 112) (print only)

Small Claims Petition for Hearing (print only)

Conversion list of Standard Industrial Classification (SIC) industry codes to North American Industry Classification (NAICS) industry codes

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Self-Insurance Forms

If you are currently self-insured, you do not need to resubmit a new security form unless that form of security or amount is being changed.

Self-Insurance Application

Self-Insurance Application in Microsoft Excel format

Self-Insurance Application in Adobe PDF format

Aggregate Surety Bond

Assumption of Self-Insurance Obligations

Irrevocable Letter of Credit

Irrevocable Trust Agreement

Self-Insured Employer's Plan for Case Management

Trust Operational Agreement

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Case Management and Dispute Resolution Forms

Case Management Plan Certification Application

Complete the Case Management Plan Certification Application online, then print for mailing.

Print, then complete the Case Management Plan Certification Application

For information on mediation, please visit our What to Expect in Mediation page.

Please note: It is no longer necessary to file the annual Medical Case Management Compliance Certificate with the South Dakota Division of Labor and Management.

Company-Specific Dispute Resolution Forms

The following case management companies have provided dispute resolution forms. For companies not listed, the generic form may be used.

Alaris

Corvel

Coventry  (See instructions for the Coventry form.)

DynaPro

Generic form

Genex

Intracorp

OHARA

Stubbe

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Scholarship Opportunity for Survivor Children

Kids' Chance of South Dakota offers higher education scholarships to children of severely or fatally injured employees. Visit www.kidschanceofsd.org for more information and the scholarship application form (Adobe PDF format). Please note, this information is provided as a courtesy to Kids' Chance of South Dakota; the South Dakota Department of Labor and Regulation is not involved in this scholarship program.

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Can't Find a Form?

If you cannot find, above, the form you need, please contact us.