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South Dakota Department of Labor CASE MANAGEMENT Division of Labor and Management COMPLIANCE CERTIFICATION Claim Administrator Information: Claim Administrator Federal ID No ___________________ Carrier Code__________ Name (DBA) _____________________________________________ Address ___________________________________ City __________________ State _______ Zip ____________ Telephone Number ____________________ Form Completed By _______________________________________ Case Management Provider Information: We certify, as an insurer, we have engaged the services of the following certified case management plan provider: Case Management Provider Federal ID No. ________________________________ Case Management Provider Name (DBA) ____________________________________________________________ Case Management Provider Mailing Address Line 1 ______________________________ _____________________ Case Management Provider Mailing Address Line 2 ______________________________ _____________________ Case Management Provider City ________________________________ State ________ Zip _________________ Case Management Provider Telephone No. __________________________________ and further certify that all workers’ compensation insu rance policies issued or renewed by the insurer provide case management services to its insured. This certificat ion shall be filed with the South Dakota Department of Labor by March 31 of each year to demonstrate compliance with SDCL 58-20-24 or SDCL 62-5-21. Submitted by _____________________________________________ Date________________________ (Representative of the Insurer) Submit form to: South Dakota Department of Labor Division of Labo r and Management 700 Governors Drive Pierre, SD 57501-2291 Telephone (605)773-3681 DOL-LM-MC1 Revised 06/06/2003