Form 0807 V1 - Calculation Of Compensation
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SD EForm -
0807
V1
HELP
Division of Labor and Management
CALCULATION OF COMPENSATION
Claim Administrator Information:
Claim Administrator Federal ID No _________________________ Carrier Code ______________ Claim # ______________
Name (DBA) _____________________________________________
Address ________________________________________ City _______________________ State _______ Zip ____________
Telephone Number _______________________ Form Completed By ______________________________________________
Employer Information:
Employer Federal ID No ________________________ Employer Name (DBA) ______________________________________
Employee/Injury Information:
Employee/Claimant SSN __________________________ Date of Injury _______________________
Body Part(s) Injured ________________ ________________ _______________ ______________
Employee/Claimant Name ______________________________________ ____________________________ _______
(Last)
(First)
(MI)
Compensation Information:
Date Disability Began _______________________
Gross Average Weekly Wage: ______________________
(Please attach wage statement)
Please attach a statement of all wages the claimant is known to have been receiving from this or any
other employment at the time immediately preceding the injury. If no wage statement is available please
explain how the average weekly wage was calculated.
Compensation will be paid at the rate of _______________ per week, to be paid (please indicate one of the following)
Weekly
Bi-Weekly
Monthly
Other (please specify) _________________________________________
beginning ______________ until terminated in accordance with the provisions of the Workers’ Compensation Laws of the
State of South Dakota.
This document does not constitute an agreement, stipulation, or release. This document does not affect the employee’s right
to seek benefits, including a change in the rate of compensation, nor does it restrict the employer/insurer’s right to deny any
claim. This form is meant to lead to an understanding between the parties regarding the rate of compensation.
No party is required to sign this form in order to make payments or receive payment of benefits.
Claimant/Employee Signature ________________________________________________ Date __________________
Employer Signature _________________________________________________________ Date __________________
Claim Administrator Signature _______________________________________________ Date __________________
SD Department of Labor and Regulation
PRINT FOR MAILING
CLEAR FORM
Division of Labor and Management
700 Governors Dr
DLR-LM-110 Revised 03/20/2012
Pierre, SD 57501-2291
Tel. 605.773.3681
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