South Dakota Department of Labor Division of Labor and Management MONTHLY PAYMENT REPORT Workers’ Compensation Expenditure Report for _______________ ____________ (month) (year) 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) Payment Information: DISABILITY 210 - Temporary Partial 220 - Temporary Total 230 - Permanent Partial 240 - Permanent Total 250 - Rehabilitation 260 - Disability Settlement/Lump Sum Date of Disability _______________ _______________ _______________ _______________ _______________ _______________ No. of Weeks Paid ________________ ________________ ________________ ________________ ________________ ________________ Amount Paid ____________ ____________ ____________ ____________ ____________ ____________ Date of Fatality: _______________ FATALITY 312 - Fatality Payments 311 - Fatality Settlement/Lump Sum No. of Weeks Paid ________________ ________________ Amount Paid ____________ ____________ MEDICAL EXPENSES: 102 – Chiropractor 113 - Counseling Services 103 – Dentist 104 - Doctor 105 - Equipment 115 - Home Health Care 101 - Hospital 106 - Pharmacy 110 - Physical Therapy Fees 109 - Radiology 107 - Transportation 108 - Other Medical Expenses 118 - IME Amount Paid _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ MISCELLANEOUS EXPENSES: 402- Interest to Claimant 404 – Deductible Reimbursement 112 - Investigative Fees 111 - Legal Fees 403 - Penalty Charged to Employer 114 - Rehabilitation Consultant 401 - Subrogation 117 – Case Management Fees 116 - Miscellaneous Expenses (please specify)______________________________________ Submit form to: DOL-LM-107 Revised 07/01/2008 Amount Paid ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ 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