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		South Dakota Employer’s First Report of Injury
			(See Instructions on Second Page)
E	SSN:	Date of Birth:	Gender: M	F	Dependents:	Education:
E	SSN:	Date of Birth:	Gender: M	F	Dependents:
M	Name: (Last)		(First)		( Middle initial)	Less than High School
P	Name: (Last)		(First)		( Middle initial)	Less than High School
L	Mailing Address:
O	City:	State:	Zip:		Telephone No.:	GED or High School
Y
E	Employee signature: (X) _______________________________________________________Date_________________					Beyond High School
E

Date of Injury:

Time of Injury:

a.m.

p.m.

Fatality Date (if applicable):

(See Codes on Second Page)

Body Part Injured

County Where Injury Occurred:

Was Safety Equipment Provided? Yes

or No

Time Work Day Began on Date of Injury:

a.m.

p.m.

Was Safety Equipment Used? Yes

or No

(If code 90, Multiple Injury, please specify

body part codes for each body part injured.)

Date Returned to Work (if applicable):

Did Injury Occur on Employer Premises? Yes

or No

YAddress or Location of Injury:

/	Description of Injury:
T	Description of Injury:
R
R				Nature of Injury
E				Nature of Injury
E
A	Date Employer Notified of Injury:
T	Injury Reported to:		Witness:	Cause of Injury
M	Injury Reported to:		Witness:
M
E
E
N	Type of Treatment (please check one)	If treatment sought, please specify provider of treatment:
T	Type of Treatment (please check one)

Doctor, Clinic or Hospital Name:

No Treatment

Mailing Address:

On-Site Treatment

City:StateZip

Clinic

Telephone No. :

Emergency Room

Hospitalization

EMPLOYER/EMPLOYMENT INFORMATION:

Federal ID No.:

# Employees:

Employment Type:

Regular or

Temporary

Employer Name (DBA):

Emp. Status:

Seasonal

Volunteer

Mailing Address:

Date Employee Hired:

Employee’s Position:

City:

State:

Zip:

Employee’s Time in Current Position:

Telephone No. :

County Where Employer Located:

Employee’s Hours Per Week:

Employer signature: ______________________________________________________Date____________________

Employee’s Current Wage:

per

CLAIM OFFICE INFORMATION

Check if Claim Office is same as Insurance Provider

If not, you must complete the following

NAICS for Employer Being Insured (Nature of Business):

UNDERLYING INSURANCE PROVIDER INFORMATION

Carrier Code

FEIN (Claim Office)

Carrier Code (If applicable)

FEIN (Insurance Provider)

Claim Office

Claim Office Address

Represented Entity Name

City

State

ZipCode

Address

Telephone

City

State

Zip Code

Email Address

Telephone Number

Claim Office Claim #

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

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	44	Chest, including ribs sternum, soft ribs	78	Ring finger at metacarpal bone
03	Blindness both eyes	48	Internal organs-other than heart, lungs	79	Ring finger at proximal joint
04	Deafness both ears	49	Heart	80	Ring finger at middle joint
05	Deafness one ear	51	Hip	81	Ring finger at distal joint
10	Multiple head injury	52	Upper leg	82	Little finger at metacarpal bone
11	Skull	53	Knee	83	Little finger at proximal joint
12	Brain	54	Lower leg	84	Little finger at middle joint
13	Ear(s)	55	Ankle	85	Little finger at distal joint
14	Eye(s)	56	Foot	86	Great toe metatarsal bone
17	Mouth	57	Toe (other than greater)	87	Great toe at proximal joint
19	Face (facial bones)	58	Toe (greater)	88	Great toe at distal joint
20	Multiple neck injury	60	Lungs	90	Multiple injury
21	Vertebrae	61	Groin	92	Other toe metatarsal bone
22	Disc	67	Thumb metacarpal bone	93	Other toe at proximal joint
24	Other	68	Thumb at proximal joint	94	Other toe at middle joint
31	Upper arm	69	Thumb at distal joint	95	Other toe at distal joint
32	Elbow	70	Index finger at metacarpal bone	96	Little toe metatarsal bone
33	Lower Arm-forearm	71	Index finger at proximal joint	97	Little toe at distal joint
34	Wrist	72	Index finger at middle joint
35	Hand	73	Index finger at distal joint
37	Thumb	74	Middle finger at metacarpal bone
38	Shoulder	75	Middle finger at proximal joint
41	Upper Back	76	Middle finger at middle joint
42	Lower Back	77	Middle finger at distal joint

Cause of Injury Codes				Nature of injury codes
01	Body reaction/over reaction	70	Striking against or stepping on
	(includes chemicals)			00	Not applicable
				01	Allergy
03	Temperature extremes	78	Struck or injured by moving parts of machine	02	Disfigurement
13	Caught in/under/between	81	Struck or injured, includes knife or sharp object,	71	Occupational disease
			kicked, bit, etc. – struck by object, worker,	72	Hearing loss
			patient, etc.
25	Fall from elevation	89	Hostile attack-person in act of crime
29	Fall from same level	90	Other than physical cause of injury
50	Motor vehicle	94	Repetitive motion – callous, blister, etc.
56	Bending/Lifting	97	Repetitive motion-carpal tunnel syndrome, etc.
65	Machinery/Equipment	99	Other

Question	Answer
Form Name	Form Dol Lm 101
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	1830, DBA, South_Dakota, Xerxes

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