COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : South Dakota Department of Labor Division of Labor and Management Plaintiff(s) Claim Administrator Information: -against- Calendar Extension of Time Request forNo. To Investigate Workers’ Compensation Claim : JUDICIAL SUBPOENA : Claim Administrator Federal ID No _________________________ Carrier:Code ______________ Claim # ______________ Name (DBA) _____________________________________________ : Address ________________________________________ City _______________________ State _______ Zip ____________ Defendant(s) : ...................................................... Telephone Number _______________________ Form Completed By ______________________________________________ Employer Information: THE PEOPLE OF THE STATE OF NEW YORK Employer Federal ID No ________________________ Employer Name (DBA) ______________________________________ TO Employee/Injury Information: Employee/Claimant SSN __________________________ Date of Injury _______________________ GREETINGS: Body Part(s) Injured ________________ ________________ _______________ ______________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court (Last) (First) (MI) located at CountyInformation: of Extension in room , on the day of , 20 , at o'clock in the noon, and at any recessed Pursuant to SDCLdate, to a Claim Administrator (Insurer, Self-Insured Employer, the part of the Office or Third Party or adjourned 62-6-3, testify and give evidence as a witness in this action on Claim Handling Employee/Claimant Name ______________________________________ ____________________________ _______ Administrator) has twenty (20) days after the receipt of the Employer’s First Report of Injury to investigate compensability of a claim. The law also allows for a potential extension of an additional thirty (30) days. At this time, I wish to request an extension of time to investigate the above-referenced claim. Your failure to comply with this of Injury is _______________________________ This office received the Employer’s First Report subpoena on punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a This result of your failure thecomply. of Labor and Management on ________________________ report was filed with to Division The reason for Witness, Honorable the request for an extension of time to investigate is ______________________________________________ , one of the Justices of the Court in County, day of , 20 _______________________________________________________________________________________________________ Claim Administrator Signature ___________________________________________________ Date ___________________ (Attorney must sign above and type name below) Approval By the Division of Labor and Management Approval of the Request for Extension of Time to Investigate Workers’Attorney(s) for Claim Form 106 is hereby granted. Compensation By my calculations, the full fifty (50) day period expires on _____________________________. To be in compliance with South Dakota law, you must submit your decision on compensability on or before that date. Division of Labor and Management Approval Office and P.O. Address By ______________________________________________________________ (Representative of the Division of Labor and Management) DOL-LM-106 Revised 06/06/2003 Telephone No.: Submit form to: Facsimile No.: E-Mail Address: Mobile Tel. No.: 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.USCourtForms.com