Sd Eform-1830 - South Dakota Employer'S First Report Of Injury
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SD EForm - 1830 V2
Complete and use the button at the end to print for mailing.
South Dakota Employer’s First Report of Injury
(See Instructions on Second Page)
Date of Birth:
Education:
E
SSN:
Gender: M
F
Dependents:
M
Name: (Last)
(First)
( Middle initial)
Less than High School
P
Mailing Address:
L
O
City:
State:
Zip:
Telephone No.:
GED or High School
Y
(X)
E
Employee signature:
_______________________________________________________Date_________________
Beyond High School
E
(See Codes on Second Page)
Date of Injury:
Time of Injury:
a.m.
p.m.
Fatality Date (if applicable):
Body Part Injured
I
County Where Injury Occurred:
Was Safety Equipment Provided? Yes
or No
N
J
Time Work Day Began on Date of Injury:
a.m.
p.m.
Was Safety Equipment Used? Yes
or No
(If code 90, Multiple Injury, please specify
U
body part codes for each body part injured.)
Date Returned to Work (if applicable):
Did Injury Occur on Employer Premises? Yes
or No
R
Y
Address or Location of Injury:
/
Description of Injury:
T
R
Nature of Injury
E
A
Date Employer Notified of Injury:
T
Cause of Injury
Witness:
Injury Reported to:
M
E
N
If treatment sought, please specify provider of treatment:
Type of Treatment (please check one)
T
Doctor, Clinic or Hospital Name:
No Treatment
Mailing Address:
On-Site Treatment
City:
State
Zip
Clinic
Telephone No. :
Emergency Room
Hospitalization
EMPLOYER/EMPLOYMENT INFORMATION:
Federal ID No.:
# Employees:
Employment Type:
Regular or
Temporary
Emp. Status:
FT
PT
Seasonal
Volunteer
Employer Name (DBA):
Date Employee Hired:
Mailing Address:
Employee’s Position:
City:
State:
Zip:
Employee’s Time in Current Position:
Telephone No. :
County Where Employer Located:
Employee’s Hours Per Week:
Employer signature: ______________________________________________________Date____________________
Employee’s Current Wage:
$
per
CLAIM OFFICE INFORMATION
Check if Claim Office is same as Insurance Provider
If not, you must complete the following
NAICS for Employer Being Insured (Nature of Business):
UNDERLYING INSURANCE PROVIDER INFORMATION
Carrier Code
FEIN (Claim Office)
Carrier Code (If applicable)
FEIN (Insurance Provider)
Claim Office
Claim Office Address
Represented Entity Name
City
State
ZipCode
Address
Telephone
City
State
Zip Code
Email Address
Telephone Number
Claim Office Claim #
Policy Number
Effective Dates
Date Notified
Date to DOL
Adjuster / Contact Person
For information regarding the Workers’ Compensation System go to
DOL-LM-101 Revised 2/2008
PRINT FOR MAILING
CLEAR FORM
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