South Dakota Department of Labor Division of Labor and Management CALCULATION OF COMPENSATION 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: Date Disability Began _______________________ Gross Average Weekly Wage: ______________________ (Please attach wage statement) Please attach a wage statement. If no wage statement is available please explain how the average weekly wage was calculated. Compensation will be paid at the rate of Weekly Bi-Weekly _______________ per week, to be paid (please indicate one of the following) Monthly Other (please specify) _________________________________________ beginning ______________ until terminated in accordance with the provisions of the Workers’ Compensation Laws of the State of South Dakota. This document does not constitute an agreement, stipulation, or release. This document does not affect the employee’s right to seek benefits, including a change in the rate of compensation, nor does it restrict the employer/insurer’s right to deny any claim. This form is meant to lead to an understanding between the parties regarding the rate of compensation. No party is required to sign this form in order to make payments or receive payment of benefits. Claimant/Employee Signature ________________________________________________ Date __________________ Employer Signature _________________________________________________________ Date __________________ Claim Administrator Signature _______________________________________________ Date __________________ DOL-LM-110 Revised 10/30/2007 South Dakota Department of Labor Division of Labor and Management 700 Governors Drive Pierre, SD 57501-2291 Telephone (605)773-3681 American LegalNet, Inc. www.FormsWorkflow.com