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South Dakota Form Center -

Type & Print Forms - programmed for direct type and print functionality.

Each form may be downloaded in Adobe Acrobat format. Download the form by clicking on the form number below.
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Form

Description

wcfri.pdf First Report of Injury - Employer's form (insurers must use online management system to file the First Report of Injury with the Department of Labor and Regulation.)
hearing.pdf Petition for Hearing
Medical_Petition_for_Hearing.pdf Petition for Hearing on Medical Benefits
mediation.pdf Mediation Request Form
106.pdf Request for Extension of Time (Complete and submit online using the First Report of Injury Management System)
107.pdf Monthly Payment Report
110.pdf Calculation of Compensation
111.pdf Memorandum of Payment for Permanent Partial Disability
113.pdf Memorandum of Payment for Rehabilitation
Weekly_Earnings.pdf Statement of Weekly Earnings
112.pdf Finger Amputation Impairment Form
SmallClaimsPetitionForHearing.pdf Small Claims Petition for Hearing
CMDisputeResolution.pdf Dispute Resolution for Case Management Plans
WCSelf-InsuranceApplication.pdf Application to Self - Insure Workers' Compensation Liabilities
Self-InsuranceAggregateSuretyBond.pdf Self-Insurance Aggregate Surety Bond
AssumptionofSelf-InsuranceObligations.pdf Assumption of Self-Insurance Obligations
IrrevocableLetterofCredit.pdf Irrevocable Letter of Credit
IrrevocableTrustAgreement.pdf Irrevocable Trust Agreement
Self-InsuredEmployersPlanforManagedCare.pdf Self-Insured Employers Plan for Managed Care
TrustOperationalAgreement.pdf Trust Operational Agreement
mcapp.pdf Application for Certification of Managed Care Plan
cm.pdf Case Management Compliance Certification
indcon.pdf Independent Contractor Verification Application
boss-qa.pdf Workers' Compensation - Employer Q & A
worker-qa.pdf Workers' Compensation - Employee Q & A
ThirdPartyAdministratorApplicationPacket.pdf Third Party Administrator Application Packet -
wcemployeeguide.pdf BROCHURE - An Employee's Guide to the South Dakota Workers' Compensation System
safety_poster.pdf POSTER - Safety on the Job Poster
safety_poster_spanish.pdf POSTER - Safety on the Job Poster (Spanish)