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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.
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 Application
Trucking Company Vertification Application
Injury Forms
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
Agreement to accept documents by email (one per hearing file)
Hearing File Submission Form (for electronic submission)
Mediation Request
Complete the Mediation Request online
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 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
back to topSelf-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
Assumption of Self-Insurance Obligations
Self-Insured Employer's Plan for Case Management
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 Group, Inc. (dba Paradigm Complex Care Solutions)
Coventry (See instructions for the Coventry form.)
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.
Can't Find a Form?
If you cannot find, above, the form you need, please contact us.