SOUTH DAKOTA DEPARTMENT OF LABOR DIVISION OF LABOR AND MANAGEMENT _______________________________, Claimant, HF No. v. _______________________________, Employer, SMALL CLAIMS PETITION FOR HEARING And _______________________________, Insurer. _________________________________________, Claimant, makes claim against _________________________________________, Employer, and _________________________________________, Insurer, and respectfully alleges, to Claimant's best knowledge, information and belief: 1. That I, Claimant, suffered an injury, disease or hearing loss which arose out of and in the course of my employment with Employer. 2. That Employer was self-insured, or insured by Insurer, at the time of my injury, disease or hearing loss. When I use the term “Employer” for the remainder of this petition, it will include the Insurer, if any, by reference. 3. That the South Dakota Department of Labor has previously ordered Employer to be responsible for my injury, disease or hearing loss, or has approved an agreement between Employer and me making Employer responsible. 4. That Employer has not paid the following medical costs (attach additional pages if necessary): American LegalNet, Inc. www.FormsWorkFlow.com ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ________________________________________________________________ 5. That the above costs are reasonable, medically necessary, and connected with my injury. 6. That the above costs do not exceed $8,000. 7. WHEREFORE, the Claimant petitions that the Division of Labor and Management hold a hearing and award the medical expenses to which the Claimant is entitled under South Dakota workers' compensation law. Dated this _____ day of _______________, 20 ___. Claimant's name, address, and phone number (* = required): _________________________________ Name* ____________________________________________________________________ Address (street, apt/box#, city, state)* ____________________ ___________________ Phone #* Cell # _________________________________________ Other (email, fax) 2 American LegalNet, Inc. www.FormsWorkFlow.com