Transcription of Form 107 Monthly Payment Report - state.sd.us
{{id}} {{{paragraph}}}
Example: barber
Form 107 Monthly Payment Report - state.sd.us
Workers Compensation Expenditure Report for _____ _____ )raey( )htnom(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 _____ _____ _____ )IM( )TSRIF( )TSAL( Payment Information:DISABILITY ytilibasiD fo etaD No. of Weeks Paid Amount Paid210 - Temporary Partial _____ _____ _____ 220 - Temporary Total _____ _____ _____ 230 - Permanent Partial _____ _____ _____ 240 - Permanent Total _____ _____ _____ 250 - Rehabilitation _____ _____ _____ 260 - Disability Settlement/Lump Sum _____ _____ _____ FATALITY Date of Fatalit y: _____ No.
Title: Form 107 Monthly Payment Report Author: BIT for DLR Subject: Monthly Payment Report for Workers' Comp Keywords: Workers' Comp; Monthly Payment Report; DLR; DOL; Labor and Management
Loading..
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document: