South Dakota Employer S First Report of Injury

South Dakota Employer’s First Report of Injury

On The Job Injuries

1. Upon notice of an injury, (verbal, written or otherwise) supervisors shall obtain and employees will complete, a First Report of Injury. Forms are located on BHSSC’s website (bhssc.org) and may be obtained from the Business Office. BHSSC has seven (7) days to submit a First Report of Injury to our Insurance Company, therefore completed; original forms must be submitted to the main office within three (3) days of the injury.

1. Employees can direct specific questions regarding their claim to ReliaMax. ReliaMax may contact the supervisor, employee and any witness involved in a workers compensation claim.

ReliaMax

PO Box 13369

Springfield, IL 62791

Fax: 217-726-6943

Phone: 1-866-263-7400 – please reference company name and policy number below

Company Name on Policy: BH Special Services

Policy Number: 532

1. ReliaMax may request timesheets for documentation on claims. Any time missed from work due to a workers compensation claim should be documented by the employee. Workers Compensation payment is not made for lost work time unless an employee is incapacitated for seven (7) consecutive days.

GENERAL INSTRUCTIONS

EMPLOYEE

1.Notify employer immediately of injury, as required by SDCL 62-7-10.

2.Complete all questions in the EMPLOYEE and INJURY/TREATMENT sections.

3.Sign the form.

4.Submit this form to your employer within three (3) business days after the injury.

SSN: Date of Birth: Gender: M F Dependents: Education: Check One

Name: (Last)(First)(Middle Initial)

Less than High School l

Mailing Address:

GED or High School

City:State:Zip: Telephone No.:

Beyond High School

Employee Signature: (X)Date:

(See all dropdown boxes)

Date of Injury: Time of Injury: am pmFatality Date (if applicable) Body Part Injured

County Where Injury Occurred: Was Safety Equipment Provided:yes no 00 02 Blindness one eye03 Blindness both eyes04 Deafness both ears05 Deafness one ear10 Multiple head injury11 Skull12 Brain13 Ear(s)14 Eye(s)17 Mouth19 Face (facial bones)20 Multiple neck injury21 Vertebrae22 Disc24 Other31 Upper arm32 Elbow33 Lower Arm-forearm34 Wrist35 Hand37 Thumb38 Shoulder41 Upper Back42 Lower Back

Time Work Day Began on Date of Injury: am pm Was Safety Equipment Used: yes no 00 44 Chest, including ribs sternum, soft ribs48 Internal organs-other than heart, lungs49 Heart51 Hip52 Upper Leg53 Knee54 Lower Leg55 Ankle56 Foot57 Toe (other than greater)58 Toe (greater)60 Lungs61 Groin67 Thumb metacarpal bone68 Thumb at proximal joint69 Thumb at distal joint70 Index finger at metacarpal bone71 Index finger at proximal joint72 Index finger at middle joint73 Index finger at distal joint74 Middle finger at metacarpal bone75 Middle finger at proximal joint76 Middle finger at middle joint77 Middle finger at distal joint

Date Returned to Work (if applicable): Did Injury Occur on Employer Premises?yes no 00 78 Ring finger at metacarpal bone79 Ring finger at proximal joint80 Ring finger at middle joint81 Ring finger at distal joint82 Little finger at metacarpal bone83 Little finger at proximal joint84 Little finger at middle joint85 Little finger at distal joint86 Great toe metatarsal bone87 Great toe at proximal joint88 Great toe at distal joint90 Multiple injury92 Other toe metatarsal bone93 Other toe at proximal joint94 Other toe at middle joint95 Other toe at distal joint96 Little toe metatarsal bone97 Little toe at distal joint

Address or Location of Injury: Nature of Injury(use dropdown box)

Description of Injury – What happened to cause injury? 00 Not Applicable01 Allergy02 Disfigurement71 Occupational Disease72 Hearing Loss

Cause of Injury(use dropdown box)

Date Employer Notified of Injury: 00 01 Body reaction/over reaction03 Temperature extremes13 Caught in/under/between25 Fall from elevation29 Fall from same level50 Motor vehicle56 Bending/Lifting65 Machinery/Equipment70 Striking against or stepping on78 Struck or injured by moving parts of machine81 Struck or injured, (see desc)89 Hostile attack-person in act of crime90 Other than physical cause of injury94 Repetitive motion-callous, blister, etc97 Repetitive motion-carpal tunnel syndrome, etc99 Other

Injury Reported to: Witness:

Type of Treatment(use dropdown box)Doctor, Clinic or Hospital Name:

No TreatmentOn-Site TreatmentClinicEmergency RoomHospitalizationMailing Address:

City: State: Zip:

Telephone No. :

EMPLOYER/EMPLOYMENT INFORMATION

Federal ID No.: 46361575# of Employees 500+Employment Type: Regular Temporary

Black Hills Special Services Cooperative (BHSSC)Employment Status: FTPTSeasonalVolunteer

PO Box 218, Sturgis, SD 57785Date Employee Hired:

Telephone 605-347-4467Employee’s Position:

County Where Employer Located: Meade CountyEmployee’s time in Current Position:

Employee’s Hours Per Week:

Employee’s Current Wage: $

CLAIM OFFICE INFORMATIONCheck 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 INFORMAITON

Carrier CodeFEIN (Claim Office)Carrier Code (If applicable)FEIN (Insurance Provider)

Claim Office

Claim Office AddressRepresented Entity Name

CityStateZipCodeAddress

TelephoneCityStateZip

Email AddressCode

Claim Office Claim #Policy Number

Effective Dates

Date NotifiedDate to DOL

Adjuster / Contact Person

GENERAL INSTRUCTIONS

EMPLOYEE

5.Notify employer immediately of injury, as required by SDCL 62-7-10.

6.Complete all questions in the EMPLOYEE and INJURY/TREATMENT sections.

7.Sign the form.

8.Submit this form to your employer within three (3) business days after the injury.

BODY PART CODES – on dropdown lists