South Dakota > Workers Compensation
Petition For Hearing - South Dakota
| Petition For Hearing Form. This is a South Dakota form and can be used in Workers Compensation . |
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SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION DIVISION OF LABOR AND MANAGEMENT _______________________________, Claimant, vs. _______________________________, Employer, and _______________________________, Insurer. PETITION FOR HEARING COMES NOW, ____________________________________________, Claimant in the above matter, respectfully shows and alleges as follows: I. That on or about the ______ day of _______________, ______, and for some time prior thereto, Claimant was employed by __________________________ in ___________________________, South Dakota. II. That the Employer was insured on the date of injury listed below under the Workers' Compensation laws of the State of South Dakota with the Insurer above named. III. That on or about the ______ day of _______________, ______, while Claimant was employed by ____________________________ Claimant suffered an injury to American LegalNet, Inc. www.FormsWorkFlow.com ________________________________, all of which arose out of and in the course of his or her employment with said Employer, In the manner following: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ IV. That thereafter and within less than three (3) days after the injury the Employer had actual knowledge of Claimant's injury. V. That the injury described above has caused Claimant to suffer the following disability or disabilities: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ WHEREFORE, Claimant requests that a hearing be had on the claim and that upon such hearing an award of worker's compensation benefits be made for any and all benefits to which Claimant is entitled under the South Dakota Workers' Compensation Act. Dated this ______ day of ____________________, _________. Petitioner's name, address, and phone number: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Social Security Number: _________________________________________________ Revised:04/11 American LegalNet, Inc. www.FormsWorkFlow.com
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