Fill and Sign the Form 107 Monthly Payment Report State of South Dakota

MEMORANDUM OF PAYMENT FOR PERMANENT PARTIAL DISABILITYFOR PER Employee/Injury Information: Employee/Claimant SSN __________________________ Date of Injury _______________________ Body Part(s) Injured ________________ ________________ _______________ ______________ Employee/Claimant Name ______________________________________ ____________________________ _______ (L ast) ( Fir st) ( MI) Compensation Information: Gros s Avera ge Weekly Wage _________________________ Claimant’s compensation rate is ___________________________________ Compensati on to be paid to the employee for perman ent physic al impairment pursu ant to SDCL 62-4-6 ( ) is ____________________. If the employe e’s perce nt of physica l impairment incre ases as a resul t of such work-related injury in the future, the employer/insurer may be responsible to pay the emplo yee such addi tional compensati on as is me dically determined to be applicable. If additi onal medical treatment is require d in the future as a result of such inju ry, the employer/in surer 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/h er right to pursue any benefits to which he/she may be entitled. Claimant/Employee Signature ________________________________________________________ Date _______________ Claim Administrator Signature _______________________________________________________ Date _______________ Division of La bor and Ma nagement Approval by: _______________ ________________________ Date _______________ A doctor’s impairment rating must be submitted with the Form 111 to the Division of Labor and Management. DLR-LM-111Revi sed 02/06/2017 SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION DIVISION OF LABOR AND MANAGEMENT Tel: 605.773.3681 dlr.sd.gov Cla im Administrator Information: Cla im Administrato r Federa l ID No _________________________ Ca rrier Code ______________ Cla im # ______________ Na me (DBA) _____________________________________________ A ddress ________________________________________ City ______________________ _ Stat e _______ Z ip ____________ Telephon e Nu mber _______________________ Fo rm Complete d By ______________________________________________ Employer Information: Employe r Federa l ID No ______________________ __ Employe r Na me (DBA ) ______________________________________ Completed and signed form should be mailed to the insurance company SD EForm - 0809 V1