Form 0809 V1 - Memorandum Of Payment For Permanent Partial Disability
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SD EForm -
0809
V1
HELP
MEMORANDUM OF PAYMENT
Division of Labor and Management
FOR PERMANENT PARTIAL DISABILITY
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:
Gross Average Weekly Wage _________________________
Claimant’s compensation rate is ___________________________________
Compensation to be paid to the employee for permanent physical impairment pursuant to SDCL 62-4-6 (
)
is ____________________.
If the employee’s percent of physical impairment increases as a result of such work-related injury in the future, the
employer/insurer may be responsible to pay the employee such additional compensation as is medically determined to be
applicable.
If additional medical treatment is required in the future as a result of such injury, the employer/insurer may be obligated to
pay such future medical expenses.
This memorandum is a receipt only. It does not constitute an agreement, stipulation or release. The Division of Labor and
Management retains jurisdiction as to all issues. The employee does not waive his/her right to pursue any benefits to which
he/she may be entitled.
Claimant/Employee Signature ________________________________________________________ Date _______________
Claim Administrator Signature _______________________________________________________ Date _______________
Division of Labor and Management Approval by: _______________________________________ Date _______________
A doctor’s impairment rating must be submitted with the Form 111 to the Division of Labor and Management.
SD Department of Labor and Regulation
Division of Labor and Management
700 Governors Dr
DLR-LM-111Revised 03/20/2012
Pierre, SD 57501-2291
Tel. 605.773.3681
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