Department of Labor and Regulation

Title - Workers' Compensation

Forms

Many forms used in the Workers' Compensation program are available from this page, organized into the following categories.

Injury Forms

Self-Insurance Forms

Case Management and Dispute Resolution Forms

Independent Contractor Verification Form (complete online, then print for mailing)

Injury Forms

Unless otherwise specified, the forms are in fillable Adobe .pdf format*.

First Report of Injury

It is mandatory that all insurers use the online management system to file the First Report of Injury with the Department of Labor and Regulation.

Filing Online using the First Report of Injury Management System (for insurance companies only)

If you are doing simple online data entry, all you need is a userid and a password. These can be obtained by emailing or calling the Division of Labor & Management at 605.773.3681.

If you want to do a bulk file transfer of these forms, you will need a userid, a password and initial transfer testing. Call Bill Bishop, Senior Programmer/Analyst, at 605.626.2222, ext. 4275 to arrange for testing.
Instructions for using the online system are in the Claim Administrators documentation. (Adobe .pdf file*)

First Report of Injury Management System

Fillable Adobe .pdf First Report of Injury Form (for employees and employers only)

Another option for completing the First Report of Injury (Form 101) is to complete a fillable Adobe .pdf* file on the computer, then print and mail it to us, following the instructions on page 2 of the form.

First Report of Injury - Fillable Adobe .pdf format*

Petition for Hearing (complete online, then print for mailing) or choose to
  [print, then complete]

Petition for Hearing on Medical Benefits

Mediation Request (complete online, then print for mailing) or choose to
  [print, then complete]

Request for Extension of Time (Complete and submit online using
  the First Report of Injury Management System)

Monthly Payment Report (Form 107) (Complete online, then print for mailing)
    Or, you may complete and submit online using the First Report of Injury
   Management System
.

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

Unless otherwise noted, all forms are in Adobe .pdf format* and must be printed and then filled out. 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 (Pre-fill, then print the form) (Excel format)

Self-Insurance Application

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 (Adobe .pdf format*; print only)

Case Management Plan Certification Application (Adobe .pdf format*; pre-fill, then print the form)

For more 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.

The following case management companies have provided dispute resolution forms. For companies not listed, the generic form may be used. All forms are in Adobe .pdf format* and must be printed and then filled out.

Alaris

Corvel

Coventry  (Click here for form instructions.)

DynaPro

Generic form

Genex

Intracorp

OHARA

Stubbe

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If you cannot find, above, the form you need, please contact the Division of Labor and Management.

South Dakota Department of Labor and Regulation
Division of Labor and Management
700 Governors Drive
Pierre, SD 57501
Phone: 605.773.3681
email

*Opening and printing Adobe .pdf files requires Adobe Acrobat Reader. Click here as needed to download the free Adobe Acrobat Reader.


Marcia Hultman, Secretary
700 Governors Drive
Pierre, SD 57501-2291
Tel. 605.773.3101
Fax. 605.773.6184