Fillable South Dakota Employers First Report of Injury (National American Insurance Company)

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South Dakota Employers First Report of Injury (National American Insurance Company)

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South Dakota Employer’s First Report of Injury
(See Instructions on Second Page)
E
M
P
L
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SSN: Date of Birth: Gender: M F Dependents:
Name: (Last) (First) ( Middle initial)
Mailing Address:
City: State: Zip: Telephone No.:
Employee signature: (X) _______________________________________________________Date_________________
Education:
Less than High School
GED or High School
Beyond High School
Date of Injury: Time of Injury: a.m. p.m. Fatality Date (if applicable):
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
Date Returned to Work (if applicable): Did Injury Occur on Employer Premises? Yes or No
Address or Location of Injury:
Description of Injury:
Date Employer Notified of Injury:
Injury Reported to: Witness:
(See Codes on Second Page)
Body Part Injured
(If code 90, Multiple Injury, please specify
body part codes for each body part injured.)
Nature of Injury
Cause of Injury
I
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J
U
R
Y
/
T
R
E
A
T
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Type of Treatment (please check one)
No Treatment
On-Site Treatment
Clinic
Emergency Room
Hospitalization
If treatment sought, please specify provider of treatment:
Doctor, Clinic or Hospital Name:
Mailing Address:
City: State Zip
Telephone No. :
EMPLOYER/EMPLOYMENT INFORMATION:
Federal ID No.: # Employees:
Employer Name (DBA):
Mailing Address:
City: State: Zip:
Telephone No. : County Where Employer Located:
Employer signature: ______________________________________________________Date____________________
Employment Type: Regular or Temporary
Emp. Status: FT PT Seasonal Volunteer
Date Employee Hired:
Employee’s Position:
Employee’s Time in Current Position:
Employee’s Hours Per Week:
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
City State ZipCode
Telephone State Zip Code
Email Address T
Claim Office Claim #
Date Notified Date to DOL
Represented Entity Name
Address
City
For information regarding the Workers’ Compensation System please visit www.sdjobs.org
DLR-LM-101 Revised 3/2012
Adjuster/Contact Person
Adjuster/Contact Person
Policy Number
Telephone Number
Effective Dates
HELP
PRINT FOR MAILING
CLEAR FORM
SD EForm -
1830
V2
Complete and use the button at the end to print for mailing.
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.
BODY PART CODES
02 Blindness one eye 44 Chest, includ
ing 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
(includes chemicals)
70 Striking against or stepping on
00
01
Not applicable
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,
kicked, bit, etc. – struck by object, worker,
patient, etc.
71
72
Occupational disease
Hearing loss
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
or and Regulation South Dakota Department of Lab
Division of Labor and Management
700 Governors Dr
Pierre, SD 57501-2291
www.sdjobs.org
Tel. 605.773.3681
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South Dakota Employers First Report of Injury (National American Insurance Company)

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Completed 29 July 2021

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