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Fill and Sign the Sydexnet People Searchlaura Deal Dana L Christensen Form

Fill and Sign the Sydexnet People Searchlaura Deal Dana L Christensen Form

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Open the document and fill out all its fields.
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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

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How to Sign a PDF Online How to Sign a PDF Online

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How to Sign a PDF Using Google Chrome How to Sign a PDF Using Google Chrome

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How to Sign a PDF in Gmail How to Sign a PDF in Gmail How to Sign a PDF in Gmail

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How to Sign a PDF on a Mobile Device How to Sign a PDF on a Mobile Device How to Sign a PDF on a Mobile Device

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How to Sign a PDF on iPhone How to Sign a PDF on iPhone

How to fill out and sign forms on iOS

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How to Sign a PDF on Android How to Sign a PDF on Android

How to fill out and sign documents on Android

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