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 36 State Forms found

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FIRST REPORT OF INJURY

 DLR-LM-101 Revised 08/2024

WORKERS’ COMPENSATION MEDIATION REQUEST

 No Form Number Rev. 12/2023

Request for Extension of Time - Electronic Submission Only

 DLR-LM-106 Revised 03/12/2012

APPLICATION FOR CERTIFICATION OF CASE MANAGEMENT PLAN

 SD EForm - 0815 V1 Revised 07-2023

ASSUMPTION OF SELF-INSURANCE OBLIGATIONS

 No Form Number REV 08/2018

CALCULATION OF COMPENSATION

 DLR-LM-110 Revised 02-06-2017

This is a Duplicate of ID 2629 APPLICATION FOR CERTIFICATION OF CASE MANAGEMENT PLAN

 No Form Number DEACTIVATED REV 5/20

STUBBE DISPUTE RESOLUTION FORM

 No Form Number No Form/Revision Date

DISPUTE RESOLUTION For Case Management Plans

 No Form Number No Form/Rev Date

FINGER AMPUTATION IMPAIRMENT FORM

 DOL-LM-112 Revised 04/05

INTRACORP Dispute Resolution Form

 No Form Number No Form/Rev Date

IRREVOCABLE LETTER OF CREDIT

 No Form Number Revised 2/2017

IRREVOCABLE TRUST AGREEMENT

 No Form Number No Form/Rev Date

MEMORANDUM OF PAYMENT FOR REHABILITATION

 DLR-LM-113 Revised 02/06/2017

MONTHLY PAYMENT REPORT

 DLR-LM-107 Revised 08/06/2018
Disclaimer: These forms may not be the most recent version. South Dakota may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on this site. Please check official sources.
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