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Calculation Of Compensation DLR-LM-110 - South Dakota

Calculation Of Compensation Form. This is a South Dakota form and can be used in Workers Compensation .
 Fillable pdf Last Modified 5/11/2014
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Division of Labor and Management Claim Administrator Information: CALCULATION OF COMPENSATION Claim Administrator Federal ID No _________________________ Carrier Code ______________ Claim # ______________ Name (DBA) _____________________________________________ Address ________________________________________ City _______________________ State _______ Zip ____________ Telephone Number _______________________ Form Completed By ______________________________________________ Employer Information: Employer Federal ID No ________________________ Employer Name (DBA) ______________________________________ Employee/Injury Information: Employee/Claimant SSN __________________________ Date of Injury _______________________ Body Part(s) Injured ________________ ________________ _______________ ______________ Employee/Claimant Name ______________________________________ ____________________________ _______ (Last) (First) (MI) Compensation Information: Date Disability Began _______________________ Gross Average Weekly Wage: ______________________ (Please attach wage statement) Please attach a wage statement. If no wage statement is available please explain how the average weekly wage was calculated. Compensation will be paid at the rate of _______________ per week, to be paid (please indicate one of the following) Weekly Bi-Weekly Monthly Other (please specify) _________________________________________ beginning ______________ until terminated in accordance with the provisions of the Workers' Compensation Laws of the State of South Dakota. This document does not constitute an agreement, stipulation, or release. This document does not affect the employee's right to seek benefits, including a change in the rate of compensation, nor does it restrict the employer/insurer's right to deny any claim. This form is meant to lead to an understanding between the parties regarding the rate of compensation. No party is required to sign this form in order to make payments or receive payment of benefits. Claimant/Employee Signature ________________________________________________ Date __________________ Employer Signature _________________________________________________________ Date __________________ Claim Administrator Signature _______________________________________________ Date __________________ SD Department of Labor and Regulation Division of Labor and Management 700 Governors Dr Pierre, SD 57501-2291 Tel. 605.773.3681 American LegalNet, Inc. DLR-LM-110 Revised 03/20/2012
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