Independent Contractor Verification Form (complete online, then print for mailing)
Unless otherwise specified, the forms are in fillable Adobe .pdf format*.
First Report of Injury
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 e-mailing 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*)
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*
Request for Extension of Time (Form 106) (Complete and submit online using
the First Report of Injury Management System)
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 codesback to top
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)
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.
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
*Opening and printing Adobe .pdf files requires Adobe Acrobat Reader. Click here as needed to download the free Adobe Acrobat Reader.