Monthly Payment Report {DOL-LM-107} | Docx | South Dakota

Monthly Payment Report {DOL-LM-107}

South Dakota/Workers Compensation/
Monthly Payment Report {DOL-LM-107} |  Docx | South Dakota

Monthly Payment Report Form

This is a South Dakota form that can be used for Workers Compensation.

Last updated: 9/11/2015
South Dakota Department of Labor Division of Labor and Management MONTHLY PAYMENT REPORT Workers Compensation Expenditure Report for _______________ ____________ (month) (year) Claim Administrator Information: 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) Payment Information: DISABILITY Date of Disability No. of Weeks Paid Amount Paid 210 - Temporary Partial _______________ ________________ ____________ 220 - Temporary Total _______________ ________________ ____________ 230 - Permanent Partial _______________ ________________ ____________ 240 - Permanent Total _______________ ________________ ____________ 250 - Rehabilitation _______________ ________________ ____________ 260 - Disability Settlement/Lump Sum _______________ ________________ ____________ FATALITY Date of Fatality: _______________ No. of Weeks Paid Amount Paid 312 - Fatality Payments ________________ ____________ 311 - Fatality Settlement/Lump Sum ________________ ____________ MEDICAL EXPENSES: Amount Paid MISCELLANEOUS EXPENSES: Amount Paid 102 Chiropractor _______________ 402- Interest to Claimant ____________ 113 - Counseling Services _______________ 404 Deductible Reimbursement ____________ 103 Dentist _______________ 112 - Investigative Fees ____________ 104 - Doctor _______________ 111 - Legal Fees ____________ 105 - Equipment _______________ 403 - Penalty Charged to Employer ____________ 115 - Home Health Care _______________ 114 - Rehabilitation Consultant ____________ 101 - Hospital _______________ 401 - Subrogation ____________ 106 - Pharmacy _______________ 116 - Miscellaneous Expenses ____________ (please specify)______________________________________ 110 - Physical Therapy Fees _______________ 109 - Radiology _______________ 107 - Transportation _______________ 108 - Other Medical Expenses _______________ please specify)________________________________ Submit form to: South Dakota Department of Labor Division of Labor and Management 700 Governors Drive Pierre, SD 57501-2291 DOL-LM-107 Revised 03/31/2004 Telephone (605) 773-3681