South Dakota > Workers Compensation
Memorandum Of Payment For Permanent Partial Disability DOL-LM-111 - South Dakota
| Memorandum Of Payment For Permanent Partial Disability Form. This is a South Dakota form and can be used in Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Division of Labor and Management Claim Administrator Information: MEMORANDUM OF PAYMENT FOR PERMANENT PARTIAL DISABILITY 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: Gross Average Weekly Wage _________________________ Claimant's compensation rate is ___________________________________ Compensation to be paid to the employee for permanent physical impairment pursuant to SDCL 62-4-6 ( is ____________________. If the employee's percent of physical impairment increases as a result of such work-related injury in the future, the employer/insurer may be responsible to pay the employee such additional compensation as is medically determined to be applicable. If additional medical treatment is required in the future as a result of such injury, the employer/insurer may be obligated to pay such future medical expenses. This memorandum is a receipt only. It does not constitute an agreement, stipulation or release. The Division of Labor and Management retains jurisdiction as to all issues. The employee does not waive his/her right to pursue any benefits to which he/she may be entitled. Claimant/Employee Signature ________________________________________________________ Date _______________ Claim Administrator Signature _______________________________________________________ Date _______________ Division of Labor and Management Approval by: _______________________________________ Date _______________ ) A doctor's impairment rating must be submitted with the Form 111 to the Division of Labor and Management. SD Department of Labor and Regulation Division of Labor and Management 700 Governors Dr Pierre, SD 57501-2291 www.sdjobs.org Tel. 605.773.3681 American LegalNet, Inc. www.FormsWorkFlow.com DLR-LM-111Revised 03/20/2012
|
|||||||
