Workers' Compensation

Many forms used in the Workers' Compensation program are available from this page, organized into the following categories. Unless otherwise noted, the forms are provided in Adobe PDF format.

Independent Contractor Forms

Injury Forms

Petition for Hearing

Agreement to accept documents by email (one per hearing file)

Mediation Request

Request for Extension of Time (Complete and submit online using the First Report of Injury Management System after reading important instructions.)

Monthly Payment Report (Form 107)

Complete the Monthly Payment Report online, then print for mailing.

Complete and submit online using the First Report of Injury Management System after reading important instructions.

Hand Diagram (Form 112) (print only)

Conversion list of Standard Industrial Classification (SIC) industry codes to North American Industry Classification (NAICS) industry codes

Self-Insurance Forms

If you are currently self-insured, you do not need to resubmit a new security form unless that form of security or amount is being changed.

Self-Insurance Application

Case Management and Dispute Resolution Forms

Case Management Plan Certification Application

For information on mediation, please visit our What to Expect in Mediation page.

Please note: It is no longer necessary to file the annual Medical Case Management Compliance Certificate with the South Dakota Division of Labor and Management.

Company-Specific Dispute Resolution Forms

The following case management companies have provided dispute resolution forms. For companies not listed, the generic form may be used.

ALARIS Group, Inc. (dba Paradigm Complex Care Solutions)

Scholarship Opportunity for Survivor Children

Kids' Chance of South Dakota offers higher education scholarships to children of severely or fatally injured employees. Visit www.kidschanceofsd.org for more information and the scholarship application form (Adobe PDF format). Please note, this information is provided as a courtesy to Kids' Chance of South Dakota; the South Dakota Department of Labor and Regulation is not involved in this scholarship program.

Can't Find a Form?

If you cannot find, above, the form you need, please contact us.

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