| skip to Main Navigation skip to Main Content skip to Footer Contact Us Upcoming Events News Publications Join Our Team Marcia Hultman Cabinet Secretary Font Size: A A A Find a Form Please note: Internet Explorer is the recommended browser for state e-forms. Learn more, including special instructions for Microsoft Edge users. A Abstracter Licensing Accountancy Licensing Application ( general) template for businesses ( Microsoft Word format) Appraiser Certification Appraisal Management Company Registration Architect Registration Athletic Competition B Banking Barbers and Barber Shops C Chartered Bank Claim of Unpaid Wages Consumer Complaints Cosmetology Licensing D Discrimination Complaints E Electrical Licensing Employment Application Engineer Registration G General | skip to Main Navigation skip to Main Content skip to Footer Contact Us Upcoming Events News Publications Join Our Team Marcia Hultman Cabinet Secretary Font Size: A A A Find a Form Please note: Internet Explorer is the recommended browser for state e-forms. Learn more, including special instructions for Microsoft Edge users. A Abstracter Licensing Accountancy Licensing Application ( general) template for businesses ( Microsoft Word format) Appraiser Certification Appraisal Management Company Registration Architect Registration Athletic Competition B Banking Barbers and Barber Shops C Chartered Bank Claim of Unpaid Wages Consumer Complaints Cosmetology Licensing D Discrimination Complaints E Electrical Licensing Employment Application Engineer Registration G General |
| Application Insurance Company Filings and Forms Insurance Producer J Job Orders ( for employer seeking applicants) L Labor Market Information Center publications Landscape Architect Registration Land Surveyor Registration M Money Lender Money Transmitter Mortgage Broker Mortgage Lender Mortgage Transmitter N Nail Salon Licensing New Hire Reporting P Petition for Decertification ( for public employees) Petition for Election ( for public employees) Petition for Hearing on Grievance ( for public employees) Petition for Hearing on Unfair Labor Practice ( for public employees) Petition for Unit Determination ( for public employees) Petroleum Release Service Registration Plumbing Licensing Public Employee Labor Issues R Real Estate ( forms used in the business) Real Estate Licensing Reemployment Assistance Benefits ( formerly Unemployment Insurance Benefits) Reemployment Assistance Tax ( formerly Unemployment Insurance Tax) Request for Conciliation ( for public employees) Request for Fact Finding ( for public employees) S Securities T Trust Company U Unemployment Insurance Benefits-See Reemployment Assistance Benefits Unemployment Insurance Tax - See Reemployment Assistance Tax W Wage and Hour Issues Workers' Compensation Workforce Development Council Online Services A Appraiser Certification Program Online Renewal B Broker ( Financial) Check F First Report of Injury I Investment Advisor Search Insurance License Inquiry Services J Job Search on SDWORKS N New Hire Reporting P Post a Job Opening on SDWORKS R Real Estate Online License Renewal Reemployment Assistance Benefits Portal Reemployment Assistance - File a Claim Reemployment Assistance - Make a Payment ( Overpayments) Reemployment Assistance - Request Weekly Payment Reemployment Assistance Tax Business Registration Reemployment Assistance Quarterly Report for Businesses U W Workforce Services Online Workers’ Compensation Coverage Verification Learn About Programs A Abstracters’ Board of Examiners Adult Education and Literacy Affordable Connectivity Program ( ACP) Appraiser Certification Appraisal Management Companies Apprenticeship Athletic Commission B Banking Commission Banking Regulation Board of Accountancy Board of Barber Examiners Board of Technical Professions Boards and Commissions Bring Your A Game Training Broker-Dealer Licensing Build Dakota Scholarships Business Opportunity Registration C Career Exploration and Planning Cosmetology Commission D Dakota Roots Digital Opportunity Division of Banking Division of Insurance Division of Labor and Management Division of Securities Division of Reemployment Assistance ( formerly Division of Unemployment Insurance) E Electrical Commission Employer Connection newsletter Employer Services English as a Second Language Equal Opportunity to Services F Federal Bonding Program Federal Health Insurance Marketplace Financial Institution License Verification Foreign Labor Certification Franchise Registration G General Educational Development ( GED®) H Healthcare Reform Health Insurance Companies Marketing in South Dakota HIRE Vets Medallion Program Hot Careers Human Rights I Insurance Consumer Information Insurance License Lookup Insurance, Workers’ Compensation Investment Advisor Licensing Investor Education J Job Fairs Job Search Workshops Job Seeker Services L Labor Bulletin, South Dakota e- Labor Disputes Labor Laws Labor Market Statistics Layoff Assistance for Employers Labor Assistance for Individuals Long-term Care Insurance M Minimum Wage Money Lender Regulation Money Transmitter Regulation Mortgage Regulation Mutual Funds Regulation N National Career Readiness Certificates New Hire Reporting O Older Workers P Plumbing Commission Plumbing Licensing Posting Requirements for Employers Postsecondary Graduate Outcomes System R Real Estate Commission Real Wage Calculator Reemployment Assistance ( formerly Unemployment Insurance) Reemployment Assistance Advisory Council ( formerly Unemployment Insurance Advisory Council) Registered Apprenticeship S SDMyLife SD UpSkill SDWORKS Securities Regulation Senior Community Service Employment Program ( SCSEP) Sircon Licensing ( Insurance) South Dakota Workforce Initiatives ( SDWINS) Publications StartTodaySD Apprenticeship Program Stocks Regulation Supplemental Nutrition Assistance Program ( SNAP) T Task Force on Trust Administration Review and Reform Technical Profession Registration Temporary Assistance for Needy Families ( TANF) Termination from Employment Trade Adjustment Assistance ( TAA) Training Opportunities U Unemployment Insurance - See Reemployment Assistance Unemployment Insurance Advisory Council - See Reemployment Assistance Advisory Council Unions UpSkill V Veterans’ Services W Wage and Hour Inquiries Work-Based Learning ( WBL) Toolkit Wage estimates for specific occupations Work Opportunity Tax Credit ( WOTC) Worker Adjustment and Retraining Notification Act ( WARN) Workers’ Compensation Workers’ Compensation Advisory Council Workers’ Compensation Insurance Workforce Development Council Workforce Innovation and Opportunity Act ( WIOA) Workforce Training and Education Workkeys Y Youth Employment Home to DLR Home to Workers' Compensation Advisory Council Meetings Members Case Decisions Case Management Compensation & Other Rates Coverage General Coverage Coverage Verification Services Independent Contractors Employee's Guide to Workers' Compensation ( Adobe PDF format) First Report of Injury Forms Fraud Mediation Posting Requirements Publications Rights & Responsibilities of Employee Rights & Responsibilities of Employer Returning to Work Self-Insured Companies South Dakota Laws & Rules Survivor Benefits Workers' Compensation Forms Many forms used in the Workers' Compensation program are available from this page, organized into the following categories. Unless otherwise noted, the forms are provided in Adobe PDF format. Independent Contract Forms Injury Forms Self-Insurance Forms Case Management and Dispute Resolution Forms Application for Scholarship for Survivor Children Independent Contractor Forms Independent Contractor Affidavit of Exempt Status and Fact Sheet Independent Contractor Verification Application Trucking Company Vertification Application Injury Forms First Report of Injury Petition for Hearing Complete the Petition for Hearing form online , then print for mailing. Print the Petition for Hearing form , then complete and mail it. Petition for Hearing on Medical Benefits Agreement to accept documents by email ( one per hearing file) Hearing File Submission Form ( for electronic submission) Mediation Request Complete the Mediation Request online Request for Extension of Time ( Complete and submit online using the First Report of Injury Management System after reading important instructions .) Monthly Payment Report ( Form 107) Complete the Monthly Payment Report online , then print for mailing. Complete and submit online using the First Report of Injury Management System after reading important instructions . Calculation of Compensation ( Form 110) Memorandum of Payment for Rehabilitation ( Form 113) Statement of Weekly Earnings ( print only) Hand Diagram ( Form 112) ( print only) Small Claims Petition for Hearing ( print only) Conversion list of Standard Industrial Classification ( SIC) industry codes to North American Industry Classification ( NAICS) industry codes back to top Self-Insurance Forms If you are currently self-insured, you do not need to resubmit a new security form unless that form of security or amount is being changed. Self-Insurance Application Self-Insurance Application in Microsoft Excel format Self-Insurance Application in Adobe PDF format Aggregate Surety Bond Assumption of Self-Insurance Obligations Irrevocable Letter of Credit Irrevocable Trust Agreement Self-Insured Employer's Plan for Case Management Trust Operational Agreement back to top Case Management and Dispute Resolution Forms Case Management Plan Certification Application Complete the Case Management Plan Certification Application online , then print for mailing. Print, then complete the Case Management Plan Certification Application For information on mediation, please visit our What to Expect in Mediation page. Please note: It is no longer necessary to file the annual Medical Case Management Compliance Certificate with the South Dakota Division of Labor and Management. Company-Specific Dispute Resolution Forms The following case management companies have provided dispute resolution forms. For companies not listed, the generic form may be used. ALARIS Group, Inc. ( dba Paradigm Complex Care Solutions) Corvel Coventry ( See instructions for the Coventry form .) DynaPro Generic form Genex Intracorp OHARA Stubbe back to top Scholarship Opportunity for Survivor Children Kids' Chance of South Dakota offers higher education scholarships to children of severely or fatally injured employees. Visit www. kidschanceofsd. org for more information and the scholarship application form ( Adobe PDF format). Please note, this information is provided as a courtesy to Kids' Chance of South Dakota; the South Dakota Department of Labor and Regulation is not involved in this scholarship program. back to top Can't Find a Form? If you cannot find, above, the form you need, please contact us . 123 W. Missouri Ave. - Pierre, SD 57501 Phone: 605. 773. 3101 - For TTY services, call 711 | Fax: 605. 773. 6184 DLR Home State Home Request Public Records Equal Opportunity Accessibility Policy Contact Us Disclaimer Privacy Policy Copyright ©2016 South Dakota Department of Labor & Regulation | Application Insurance Company Filings and Forms Insurance Producer J Job Orders ( for employer seeking applicants) L Labor Market Information Center publications Landscape Architect Registration Land Surveyor Registration M Money Lender Money Transmitter Mortgage Broker Mortgage Lender Mortgage Transmitter N Nail Salon Licensing New Hire Reporting P Petition for Decertification ( for public employees) Petition for Election ( for public employees) Petition for Hearing on Grievance ( for public employees) Petition for Hearing on Unfair Labor Practice ( for public employees) Petition for Unit Determination ( for public employees) Petroleum Release Service Registration Plumbing Licensing Public Employee Labor Issues R Real Estate ( forms used in the business) Real Estate Licensing Reemployment Assistance Benefits ( formerly Unemployment Insurance Benefits) Reemployment Assistance Tax ( formerly Unemployment Insurance Tax) Request for Conciliation ( for public employees) Request for Fact Finding ( for public employees) S Securities T Trust Company U Unemployment Insurance Benefits-See Reemployment Assistance Benefits Unemployment Insurance Tax - See Reemployment Assistance Tax W Wage and Hour Issues Workers' Compensation Workforce Development Council Online Services A Appraiser Certification Program Online Renewal B Broker ( Financial) Check F First Report of Injury I Investment Advisor Search Insurance License Inquiry Services J Job Search on SDWORKS N New Hire Reporting P Post a Job Opening on SDWORKS R Real Estate Online License Renewal Reemployment Assistance Benefits Portal Reemployment Assistance - File a Claim Reemployment Assistance - Make a Payment ( Overpayments) Reemployment Assistance - Request Weekly Payment Reemployment Assistance Tax Business Registration Reemployment Assistance Quarterly Report for Businesses U W Workforce Services Online Workers’ Compensation Coverage Verification Learn About Programs A Abstracters’ Board of Examiners Adult Education and Literacy Affordable Connectivity Program ( ACP) Appraiser Certification Appraisal Management Companies Apprenticeship Athletic Commission B Banking Commission Banking Regulation Board of Accountancy Board of Barber Examiners Board of Technical Professions Boards and Commissions Bring Your A Game Training Broker-Dealer Licensing Build Dakota Scholarships Business Opportunity Registration C Career Exploration and Planning Cosmetology Commission D Dakota Roots Digital Opportunity Division of Banking Division of Insurance Division of Labor and Management Division of Securities Division of Reemployment Assistance ( formerly Division of Unemployment Insurance) E Electrical Commission Employer Connection newsletter Employer Services English as a Second Language Equal Opportunity to Services F Federal Bonding Program Federal Health Insurance Marketplace Financial Institution License Verification Foreign Labor Certification Franchise Registration G General Educational Development ( GED®) H Healthcare Reform Health Insurance Companies Marketing in South Dakota HIRE Vets Medallion Program Hot Careers Human Rights I Insurance Consumer Information Insurance License Lookup Insurance, Workers’ Compensation Investment Advisor Licensing Investor Education J Job Fairs Job Search Workshops Job Seeker Services L Labor Bulletin, South Dakota e- Labor Disputes Labor Laws Labor Market Statistics Layoff Assistance for Employers Labor Assistance for Individuals Long-term Care Insurance M Minimum Wage Money Lender Regulation Money Transmitter Regulation Mortgage Regulation Mutual Funds Regulation N National Career Readiness Certificates New Hire Reporting O Older Workers P Plumbing Commission Plumbing Licensing Posting Requirements for Employers Postsecondary Graduate Outcomes System R Real Estate Commission Real Wage Calculator Reemployment Assistance ( formerly Unemployment Insurance) Reemployment Assistance Advisory Council ( formerly Unemployment Insurance Advisory Council) Registered Apprenticeship S SDMyLife SD UpSkill SDWORKS Securities Regulation Senior Community Service Employment Program ( SCSEP) Sircon Licensing ( Insurance) South Dakota Workforce Initiatives ( SDWINS) Publications StartTodaySD Apprenticeship Program Stocks Regulation Supplemental Nutrition Assistance Program ( SNAP) T Task Force on Trust Administration Review and Reform Technical Profession Registration Temporary Assistance for Needy Families ( TANF) Termination from Employment Trade Adjustment Assistance ( TAA) Training Opportunities U Unemployment Insurance - See Reemployment Assistance Unemployment Insurance Advisory Council - See Reemployment Assistance Advisory Council Unions UpSkill V Veterans’ Services W Wage and Hour Inquiries Work-Based Learning ( WBL) Toolkit Wage estimates for specific occupations Work Opportunity Tax Credit ( WOTC) Worker Adjustment and Retraining Notification Act ( WARN) Workers’ Compensation Workers’ Compensation Advisory Council Workers’ Compensation Insurance Workforce Development Council Workforce Innovation and Opportunity Act ( WIOA) Workforce Training and Education Workkeys Y Youth Employment Home to DLR Home to Workers' Compensation Advisory Council Meetings Members Case Decisions Case Management Compensation & Other Rates Coverage General Coverage Coverage Verification Services Independent Contractors Employee's Guide to Workers' Compensation ( Adobe PDF format) First Report of Injury Forms Fraud Mediation Posting Requirements Publications Rights & Responsibilities of Employee Rights & Responsibilities of Employer Returning to Work Self-Insured Companies South Dakota Laws & Rules Survivor Benefits Workers' Compensation Forms Many forms used in the Workers' Compensation program are available from this page, organized into the following categories. Unless otherwise noted, the forms are provided in Adobe PDF format. Independent Contract Forms Injury Forms Self-Insurance Forms Case Management and Dispute Resolution Forms Application for Scholarship for Survivor Children Independent Contractor Forms Independent Contractor Affidavit of Exempt Status and Fact Sheet Independent Contractor Verification Application Trucking Company Vertification Application Injury Forms First Report of Injury Petition for Hearing Complete the Petition for Hearing form online , then print for mailing. Print the Petition for Hearing form , then complete and mail it. Petition for Hearing on Medical Benefits Agreement to accept documents by email ( one per hearing file) Hearing File Submission Form ( for electronic submission) Mediation Request Complete the Mediation Request online Request for Extension of Time ( Complete and submit online using the First Report of Injury Management System after reading important instructions .) Monthly Payment Report ( Form 107) Complete the Monthly Payment Report online , then print for mailing. Complete and submit online using the First Report of Injury Management System after reading important instructions . Calculation of Compensation ( Form 110) Memorandum of Payment for Rehabilitation ( Form 113) Statement of Weekly Earnings ( print only) Hand Diagram ( Form 112) ( print only) Small Claims Petition for Hearing ( print only) Conversion list of Standard Industrial Classification ( SIC) industry codes to North American Industry Classification ( NAICS) industry codes back to top Self-Insurance Forms If you are currently self-insured, you do not need to resubmit a new security form unless that form of security or amount is being changed. Self-Insurance Application Self-Insurance Application in Microsoft Excel format Self-Insurance Application in Adobe PDF format Aggregate Surety Bond Assumption of Self-Insurance Obligations Irrevocable Letter of Credit Irrevocable Trust Agreement Self-Insured Employer's Plan for Case Management Trust Operational Agreement back to top Case Management and Dispute Resolution Forms Case Management Plan Certification Application Complete the Case Management Plan Certification Application online , then print for mailing. Print, then complete the Case Management Plan Certification Application For information on mediation, please visit our What to Expect in Mediation page. Please note: It is no longer necessary to file the annual Medical Case Management Compliance Certificate with the South Dakota Division of Labor and Management. Company-Specific Dispute Resolution Forms The following case management companies have provided dispute resolution forms. For companies not listed, the generic form may be used. ALARIS Group, Inc. ( dba Paradigm Complex Care Solutions) Corvel Coventry ( See instructions for the Coventry form .) DynaPro Generic form Genex Intracorp OHARA Stubbe back to top Scholarship Opportunity for Survivor Children Kids' Chance of South Dakota offers higher education scholarships to children of severely or fatally injured employees. Visit www. kidschanceofsd. org for more information and the scholarship application form ( Adobe PDF format). Please note, this information is provided as a courtesy to Kids' Chance of South Dakota; the South Dakota Department of Labor and Regulation is not involved in this scholarship program. back to top Can't Find a Form? If you cannot find, above, the form you need, please contact us . 123 W. Missouri Ave. - Pierre, SD 57501 Phone: 605. 773. 3101 - For TTY services, call 711 | Fax: 605. 773. 6184 DLR Home State Home Request Public Records Equal Opportunity Accessibility Policy Contact Us Disclaimer Privacy Policy Copyright ©2016 South Dakota Department of Labor & Regulation |