South Dakota Employer’s First Report of Injury
(See Instructions on Back of Form)
E
SSN:
M
Name:
P
L
O
Y
-
-
Date of Birth:
Gender: M
F
# Dependents:
Education:
Less than High School
(Last)
(First)
GED or High School
(Middle Initial)
Beyond High School
Mailing Address:
City:
State:
Employee Signature:
SD
ZIP:
Telephone No:
(X)
(
)
-
Date:
E
E
I
Date of Injury:
Time of Injury:
N
County Where Injury Occurred:
J
Time Work Day Began on Date of Injury:
U
Date Returned to Work (if applicable):
R
Address or Location of Injury:
Y
Description of Injury:
/
Date Employer Notified of Injury:
am
am
pm
Fatality Date: (if applicable)
(See Codes on Reverse)
Was Safety Equipment Provided?
Yes
No
Was Safety Equipment Used?
Yes
No
Did Injury Occur on Employer Premises? Yes
No
pm
Body Part Injured
(If code 90, Multiple Injury,
please specify body part codes
for each body part injured.)
,
Nature of Injury
T
R
Cause of Injury
Injury Reported To:
Witness:
E
A
T
M
E
N
T
Type of Treatment (please circle one)
If treatment sought, please specify provider of treatment:
No Treatment
Doctor, Clinic or Hospital Name:
On-Site Treatment
Mailing Address:
Clinic
City:
Emergency Room
Telephone No:
State:
(
)
ZIP:
-
Hospitalization
EMPLOYER/EMPLOYMENT INFORMATION:
Federal ID No:
# Employees:
Employment Type:
Regular or
Employer Name (DBA):
Emp. Status:
Mailing Address:
Date Employee Hired:
City:
State:
Telephone No:
(
)
-
FT
PT
Temporary
Seasonal
Volunteer
Employee’s Position:
ZIP:
Employee’s Time in Current Position:
County Where Employer is Located:
Employer Signature:
Employee’s Hour Per Week:
Date:
Employee’s Current Wage:
$
per
Check if Claim Office is same as Insurance Provider
CLAIM OFFICE INFORMATION
If not, you must complete the following:
NAICS for Employer Being Insured (Nature of Business:
Carrier Code:
15377
Claim Office:
Western National Insurance Company
Claim Office Address:
City:
FEIN (Claim Office):
Carrier Code (If applicable)
P.O. Box 1463
Minneapolis
Telephone No:
UNDERLYING INSURANCE PROVIDER INFORMATION
41-0430825
(952) 835-5350
State:
FEIN (Insurance Provider)
Represented Entity Name:
MN
ZIP:
55440-1463
Address:
City:
E-mail Address:
Telephone No:
Claim Office Claim #:
Policy No:
Date Notified:
Effective Dates:
State:
ZIP:
Adjuster / Contact Person:
DOL-LM-101 06/03/2003
Submit form to: South Dakota Department of Labor
Division of Labor and Management
700 Governors Drive
Pierre, SD 57501-2291
Telephone (605) 773-3681
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.
INSURER
1. Complete all questions in the CLAIM OFFICE INFORMATION sections at the bottom of the page.
2. Submit this form within ten (10) days of its receipt, as required by SDCL 62-6-3, to:
SOUTH DAKOTA DEPARTMENT OF LABOR
Division of labor and Management
700 Governors Drive
Pierre SD 57501-2291
Tel. (605) 773-3681
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
01 Body reaction/over
reaction (includes
chemicals)
03 Temperature extremes
13 Caught in/under/between
25
29
50
56
65
Fall from elevation
Fall from same level
Motor vehicle
Bending/Lifting
Machinery/Equipment
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
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
70
Striking against or stepping on)
78
81
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
89
90
94
97
99
00 01 02 71 72
Not applicable Allergy Disfigurement Occupational disease Hearing loss
00
01
02
71
72
Not applicable
Allergy
Disfigurement
Occupational disease
Hearing loss