Form Dol-Lm-101 - South Dakota Employer'S First Report Of Injury - 2008

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South Dakota Employer’s First Report of Injury
(See Instructions on Back of Form)
Education:
E
SSN: _________________________
Date of Birth:__________________ Gender: M
F
# Dependents: ___________
M
P
Less than High School
Name: _______________________________________________________________________________________________________
L
(Last)
(First)
( Middle initial)
GED or High School
O
Mailing Address: ______________________________________________________________________________________________
Beyond High School
Y
City: ____________________________________________
State: ________ Zip:_________ Telephone No.: (____)____________
E
E
(X)
Employee signature:
____________________________________________________________Date_______________________
(See Codes on Reverse)
Date of Injury:
Time of Injury:
a.m./p.m. Fatality Date (if applicable):
Body Part Injured
I
County Where Injury Occurred:
Was Safety Equipment Provided? Yes
or No
N
(If code 90, Multiple Injury,
J
please specify body part codes for
Time Work Day Began on Date of Injury: __________________ a.m./p.m. Was Safety Equipment Used?
Yes
or No
U
each body part injured.)
R
Date Returned to Work (if applicable): _____________________ Did Injury Occur on Employer Premises? Yes
or No
Y
Address or Location of Injury: ___________________________________________________________________________________
/
T
Description of Injury: __________________________________________________________________________________________
R
_____________________________________________________________________________________________________________
E
Nature of Injury
A
Date Employer Notified of Injury: ___________________________________________________
Cause of Injury
T
Injury Reported to:
Witness:
M
E
N
If treatment sought, please specify provider of treatment:
Type of Treatment (please check one)
T
Doctor, Clinic or Hospital Name:
No Treatment
On-Site Treatment
Mailing Address: ____________________________________________________________________________________
Clinic
City: ___________________________State ____________ Zip _____________
Emergency Room
Hospitalization
Telephone No. : (______)_________________
EMPLOYER/EMPLOYMENT INFORMATION:
Federal ID No.:
# Employees:
Employment Type:
Regular or
Temporary
Employer Name (DBA):
Emp. Status:
FT
PT
Seasonal
Volunteer
Mailing Address: ________________________________________________________________________________
Date Employee Hired:
City: _____________________________________________
State: __________________ Zip: ______________
Employee’s Position: __________________________
Employee’s Time in Current Position: ___________
Telephone No. : (_______)______________________ County Where Employer Located: _____________________
Employee’s Hours Per Week: ___________________
Employer signature: ______________________________________________________Date____________________
Employee’s Current Wage:
$
per
CLAIM OFFICE INFORMATION
Check if Claim Office is same as Insurance Provider
If not, you must complete the following
NAICS for Employer Being Insured (Nature of Business):
UNDERLYING INSURANCE PROVIDER INFORMATION
Carrier Code
FEIN (Claim Office)
Carrier Code (If applicable)
FEIN (Insurance Provider)
Claim Office
Claim Office Address
Represented Entity Name
City
State
ZipCode
Address
Telephone
City
State
Zip Code
Email Address
Telephone Number
Claim Office Claim #
Policy Number
Effective Dates
Date Notified
Date to DOL
Adjuster / Contact Person
For information regarding the Workers’ Compensation System go to
DOL-LM-101 Revised 2/2008

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