SD EForm - 0810 V1 Claim Administrator Information: Claim Administrator Federal ID No Name (DBA) Address Telephone Number City Form Completed By State Zip Carrier Code v Claim # Employer Information: Employer Federal ID No Employer Name (DBA) Employee/Injury Information: Employee/Claimant SSN Body Part(s) Injured Employee/Claimant Name (Last) (First) (MI) Date of Injury Retraining/Rehabilitation Information: Claimant's Gross Average Weekly Wage $ Claimant's compensation rate is $ Compensation to be paid for rehabilitation (SDCL 62-4-5.1) is $ The compensation is based on the following information: The employee is unable to return to his/her usual and customary occupation as of The program of retraining will begin on The program of rehabilitation will begin on The program to be undertaken is as follows: (Give a brief description of the program) and end on If additional medical treatment is required in the future as a result of such injury, the employer/insurer shall be obligated to pay such future medical expenses. This memorandum is a receipt only. It does not constitute an agreement, stipulation or release. The Division of Labor and Management retains jurisdiction as to all issues. The employee does not waive his/her right to pursue any benefits to which he/she may be entitled. Claimant/Employee Signature ______________________________________________________ Date __________________ Claim Administrator Signature _____________________________________________________ Date __________________ Division of Labor and Management Approval by ___________________________________________ Date _____________ DLR-LM-113 Revised 03/20/2012 American LegalNet, Inc. www.FormsWorkFlow.com Submit form to: SD Department of Labor and Regulation Division of Labor and Management 700 Governors Dr Pierre, SD 57501-2291 www.sdjobs.org Tel. 605.773.3681