1830 V2
SD EForm -
HELP
Complete and use the button at the end to print for mailing.
South Dakota Employer’s First Report of Injury
(See Instructions on Second Page)
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SSN:
Date of Birth:
Gender: M
Name: (Last)
Mailing Address:
State:
Education:
Dependents:
(First)
City:
Employee signature:
F
( Middle initial)
Zip:
Less than High School
Telephone No.:
GED or High School
(X) _______________________________________________________Date_________________
Date of Injury:
Time of Injury:
a.m.
p.m.
County Where Injury Occurred:
Time Work Day Began on Date of Injury:
a.m.
Date Returned to Work (if applicable):
p.m.
(See Codes on Second Page)
Body Part Injured
Fatality Date (if applicable):
Was Safety Equipment Provided? Yes
Beyond High School
or No
Was Safety Equipment Used? Yes
or No
Did Injury Occur on Employer Premises? Yes
or No
(If code 90, Multiple Injury, please specify
body part codes for each body part injured.)
Address or Location of Injury:
Description of Injury:
Nature of Injury
Date Employer Notified of Injury:
Injury Reported to:
Cause of Injury
Witness:
If treatment sought, please specify provider of treatment:
Type of Treatment (please check one)
Doctor, Clinic or Hospital Name:
No Treatment
Mailing Address:
On-Site Treatment
City:
Clinic
Zip
State
Telephone No. :
Emergency Room
Hospitalization
EMPLOYER/EMPLOYMENT INFORMATION:
Federal ID No.:
# Employees:
Employment Type:
Emp. Status:
Employer Name (DBA):
Regular or
FT
PT
Seasonal
City:
State:
Telephone No. :
Employee’s Position:
Zip:
Employee’s Time in Current Position:
County Where Employer Located:
Employee’s Hours Per Week:
Employer signature: ______________________________________________________Date____________________
Employee’s Current Wage:
$
CLAIM OFFICE INFORMATION
per
Check if Claim Office is same as Insurance Provider
NAICS for Employer Being Insured (Nature of Business):
If not, you must complete the following
UNDERLYING INSURANCE PROVIDER INFORMATION
Carrier Code
Carrier Code (If applicable)
FEIN (Claim Office)
FEIN (Insurance Provider)
Claim Office
Claim Office Address
Represented Entity Name
City
State
ZipCode
Telephone
Address
City
State
Zip Code
Telephone Number
T
Policy Number
Claim Office Claim #
Effective Dates
Date Notified
Volunteer
Date Employee Hired:
Mailing Address:
Email Address
Temporary
Date to DOL
Adjuster/Contact Person
For information regarding the Workers’ Compensation System please visit www.sdjobs.org
DLR-LM-101 Revised 3/2012
PRINT FOR MAILING
CLEAR FORM
GENERAL INSTRUCTIONS
EMPLOYEE
1. Notify employer immediately of injury, as required by SDCL 62-7-10.
2. Complete all questions in the EMPLOYEE and INJURY/TREATMENT sections.
3. Sign the form.
4. Submit this form to your employer within three (3) business days after the injury.
EMPLOYER
1. Complete all questions in the EMPLOYER/EMPLOYMENT sections.
2. Sign the form.
3. Submit this form to your workers’ compensation insurance carrier within seven (7) days of knowledge of the occurrence of the injury, as required by
SDCL 62-6-2.
4. Give a copy of the form to the injured employee.
5. Keep the copy of the First Report of Injury for at least four (4) years from the date of injury, as required by SDCL 62-6-1.
BODY PART CODES
02
Blindness one eye
03 Blindness both eyes
04
Deafness both ears
05
Deafness one ear
10
Multiple head injury
11
Skull
12
Brain
13
Ear(s)
14
Eye(s)
17
Mouth
19
Face (facial bones)
20
Multiple neck injury
21
Vertebrae
22
Disc
24
Other
31
Upper arm
32
Elbow
33
Lower Arm-forearm
34
Wrist
35
Hand
37
Thumb
38
Shoulder
41
Upper Back
42
Lower Back
Cause of Injury Codes
44
48
49
51
52
53
54
55
56
57
58
60
61
67
68
69
70
71
72
73
74
75
76
77
Chest, including ribs sternum, soft ribs
Internal organs-other than heart, lungs
Heart
Hip
Upper leg
Knee
Lower leg
Ankle
Foot
Toe (other than greater)
Toe (greater)
Lungs
Groin
Thumb metacarpal bone
Thumb at proximal joint
Thumb at distal joint
Index finger at metacarpal bone
Index finger at proximal joint
Index finger at middle joint
Index finger at distal joint
Middle finger at metacarpal bone
Middle finger at proximal joint
Middle finger at middle joint
Middle finger at distal joint
01
Body reaction/over reaction
(includes chemicals)
70
Striking against or stepping on
03
13
Temperature extremes
Caught in/under/between
78
81
25
29
50
56
65
Fall from elevation
Fall from same level
Motor vehicle
Bending/Lifting
Machinery/Equipment
89
90
94
97
99
Struck or injured by moving parts of machine
Struck or injured, includes knife or sharp object,
kicked, bit, etc. – struck by object, worker,
patient, etc.
Hostile attack-person in act of crime
Other than physical cause of injury
Repetitive motion – callous, blister, etc.
Repetitive motion-carpal tunnel syndrome, etc.
Other
78
79
80
81
82
83
84
85
86
87
88
90
92
93
94
95
96
97
Ring finger at metacarpal bone
Ring finger at proximal joint
Ring finger at middle joint
Ring finger at distal joint
Little finger at metacarpal bone
Little finger at proximal joint
Little finger at middle joint
Little finger at distal joint
Great toe metatarsal bone
Great toe at proximal joint
Great toe at distal joint
Multiple injury
Other toe metatarsal bone
Other toe at proximal joint
Other toe at middle joint
Other toe at distal joint
Little toe metatarsal bone
Little toe at distal joint
Nature of injury codes
00
01
02
71
72
Not applicable
Allergy
Disfigurement
Occupational disease
Hearing loss
South Dakota Department of Labor and Regulation
Division of Labor and Management
700 Governors Dr
Pierre, SD 57501-2291
www.sdjobs.org
Tel. 605.773.3681