Fill and Sign the Welcome Claim Administrators South Dakota Department of Form

South Dakota Department of Labor Request for Extension of Time Division of Labor and Management To Investigate Workers’ Compensation Claim 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) ( Fir st) ( MI) Extension Information: Pursuant to SDCL 62-6-3, a Claim Admi nistrator (Insurer, Self-Insured Employer, Claim Handling Office or Third Party Administrator) has twenty (20) days after the receipt of th e Employer’s First Report of Inju ry to investigate compensability of a claim. The law also allows for a potential extension of an additional thirty (30) days. At this time, I wish to request an extension of time to investig ate the above-referenced claim. This office received the Employer’s First Report of Injury on _ ______________________________ This report was filed with the Division of Labor and Management on ________________________ The reason for the request for an extension of time to investigate is ______________________________________________ _______________________________________________________________________________________________________ Claim Administrator Signature ___________________________________________________ Date ___________________ Approval By the Division of Labor and Management Approval of the Request for Extension of Time to Investigate Workers’ Compensation Claim Form 106 is here by granted. By my calculations, the full fifty (50) day period expires on _____________________________. To be in compliance with South Dakota law, you must submit your decision on compensability on or before that date. Division of Labor an d Management Approval By ______________________________________________________________ (Representative of the Division of Labor and Management) Submit form to: South Dakota Department of Labor Division of Labo r and Management 700 Governors Drive DOL-LM-106 Revised 06/06/2003 Pierre, SD 57501-2291 Telephone (605)773-3681