South Dakota Employer’s First Report of Injury (See Instructions on Back of Form) E M P L O Y E E SSN: _________________________ Date of Birth:__________________ Gender: M F Education: # Dependents: ___________ Less than High School Name: _______________________________________________________________________________________________________ (Last) (First) ( Middle initial) Mailing Address: ______________________________________________________________________________________________ City: ____________________________________________ Employee signature: GED or High School Beyond High School State: ________ Zip:_________Telephone No.: (____)____________ (X) ____________________________________________________________Date_______________________ (See Codes on Reverse) Date of Injury: I N J U R Y / T R E A T M E N T Time of Injury: a.m./p.m. County Where Injury Occurred: Fatality Date (if applicable): Body Part Injured Was Safety Equipment Provided? Yes Time Work Day Began on Date of Injury: __________________ a.m./p.m. Was Safety Equipment Used? or No Yes Date Returned to Work (if applicable): _____________________ Did Injury Occur on Employer Premises? Yes (If code 90, Multiple Injury, please specify body part codes for each body part injured.) or No or No 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) No Treatment Doctor, Clinic or Hospital Name: On-Site Treatment Mailing Address: ____________________________________________________________________________________ Clinic City: ___________________________State ____________ Zip _____________ Emergency Room Telephone No. : (______)_________________ Hospitalization EMPLOYER/EMPLOYMENT INFORMATION: Federal ID No.: # Employees: Employment Type: Employer Name (DBA): Emp. Status: FT Regular or PT Seasonal Temporary Volunteer Mailing Address: ________________________________________________________________________________ Date Employee Hired: City: _____________________________________________ Employee’s Position: __________________________ State: __________________ Zip: ______________ Telephone No. : (_______)______________________ County Where Employer Located: _____________________ Employer signature: ______________________________________________________Date____________________ Employee’s Time in Current Position: ___________ Employee’s Hours Per Week: ___________________ 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 City Represented Entity Name State ZipCode Address Telephone City Email Address Telephone Number Claim Office Claim # State Zip Code Policy Number Effective Dates Date Notified Date to DOL Adjuster / Contact Person For information regarding the Workers’ Compensation System go to www.sdjobs.org DOL-LM-101 Revised 2/2008 American LegalNet, Inc. www.FormsWorkflow.com 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 www.sdjobs.org 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 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 CAUSE OF INJURY CODES 01 Body reaction/over reaction (includes chemicals) 03 Temperature extremes 13 Caught in/under/between 78 81 25 29 50 56 Fall from elevation Fall from same level Motor vehicle Bending/Lifting 89 90 94 97 65 Machinery/Equipment 99 70 Striking against or stepping on 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 00 01 02 71 72 Not applicable Allergy Disfigurement Occupational disease Hearing loss American LegalNet, Inc. www.FormsWorkflow.com