Independent Contractor Verification Form (for truck owner-operators only; complete online, then print for mailing)
Unless otherwise specified, the forms are in fillable Adobe PDF format*.
First Report of Injury
It is mandatory that all insurers use the online management system to file the First Report of Injury with the Department of Labor and Regulation.
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 user id and a password. These can be obtained by emailing 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 user id, 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 (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)
For more 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.
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.
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 (in 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.
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
123 W. Missouri Ave.
Pierre, SD 57501
*Opening and printing Adobe PDF files requires Adobe Acrobat Reader. Click here as needed to download the free Adobe Acrobat Reader.