Transcription of Form 107 Monthly Payment Report - state.sd.us
1 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.
2 Of Weeks Paid Amount Paid _____ _____ _____ _____Amount Paid ____ ___ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____MISCELLANEOUS EXPENSES: 402-Interest to Claimant404 Deductible Reimbursement112 - Investigative Fees111 - Legal Fees403 - Penalty Charged to Employer114 - Rehabilitation Consultant401 - Subrogation117 Case Management Fees116 - Miscellaneous Expenses(please specify)Amount Paid _____ _____ _____ _____ _____ _____ _____ _____ _____312 - Fatality payments 311 - Fatality Settlement/Lump Sum MEDICAL EXPENSES: 102 Chiropractor 113 - Counseling Services 103 Dentist 104 - Doctor 105 - Equipment 115 - Home Health Care 101 - Hospital 106 - Pharmacy110 - Physical Therapy Fees 109 - Radiology 107 - Transportation 108 - Other Medical Expenses 118 - IME 119- Medical Bill ReviewDLR-LM-107 Revised 08/06/2018 SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATIONDIVISION OF LABOR AND MANAGEMENT123 W.
3 Missouri Ave. Pierre, South Dakota 57501 Tel: Fax: Monthly Payment REPORT313 - Transportation & Burial Expenses
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