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South Dakota Form 112: Finger Amputation Impairment

South Dakota bases scheduled-loss benefits for finger amputations on the point of amputation under SDCL 62-4-6, and this one-page hand diagram records that point. The treating doctor marks the exact location for each affected finger and, when less than the first phalange was lost, circles the percentage of that phalange amputated. The insurer then applies the conversion formula printed on the form.

Who completes it

The treating physician completes the 'For Doctor Only' section for the right and left hand. The 'For Insurance Company Only' section is the insurer's calculation guide.

Submitting and payment

How to submit it
Return the marked diagram to the workers' compensation insurer, which applies the scheduled-loss formula.
Who pays
The form sets no fee for the physician's marking.

Good to know

  • Use it only for finger amputations; the form says so at the top, and the Division lists it as print only, so it is marked by hand.
  • Per the insurer section, loss of more than one phalange counts as the full scheduled loss and loss of one phalange as half.
  • For loss of less than one phalange, the insurer multiplies the percentage the doctor circles by 50 percent of the scheduled loss, so that percentage directly changes the benefit.
  • South Dakota has no state-prescribed physician report for work injuries generally; this diagram, revised 04/05, applies only to finger amputations.

Get the official form

Download the current version from the source each time; forms change without notice.

Finger Amputation Impairment Form

Official pagePDF

Fill it with Vero

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

How do I complete South Dakota Form 112?

Mark the exact location of the amputation on the diagram for each affected finger. If less than the first phalange was amputated, circle the percentage of the first phalange lost for that finger under the right or left hand column. Leave the insurance company section to the insurer.

How is a partial fingertip loss paid in South Dakota?

According to the form's insurer section, loss of less than one phalange equals the percentage of loss times 50 percent of the scheduled loss for that finger. That is why the doctor's circled percentage of the first phalange amputated is the key entry. The schedule itself is in SDCL 62-4-6.