Forms

Fillable Forms and Resources

  • This site supports Fillable PDF forms and can be found by searching by the state form number (SFN), title or agency that owns the form.
  • Definitions:
    • Internal Forms: Forms used by customers internal to North Dakota State Government.
    • Public Forms: Forms used by the general public or entities external to North Dakota State Government
Important: These forms MUST be downloaded to function properly (may contain automatic calculations, field validations, tab order, etc.). Using the PDF viewer within the browser disables this functionality.

Insurance Department - Internal Form(s)

SFNTitleSizeDateFillable
52579 PAYMENT VOUCHER/AUTHORIZATION 439 kb 10/23/2015 Y
54180 LARGE GROUP HEALTH INSURANCE DATA REPORT 85 kb Y
54181 SMALL GROUP HEALTH INSURANCE DATA REPORT 77 kb Y
54182 INDIVIDUAL HEALTH INSURANCE DATA REPORT 100 kb Y
58370 PRESCRIPTION CONNECTION INTAKE APPLICATION 1492 kb 08/12/2020 Y
61674 INSURANCE PRODUCER DISCLOSURE - FEES FOR INSURANCE SERVICES 896 kb 08/20/2019 Y
61675 DISCOUNT PLAN ORGANIZATION APPLICATION 926 kb 08/21/2019 Y
61702 SURETY BOND OF DISCOUNT PLAN ORGANIZATIONS 953 kb 10/02/2019 Y
61886 STATE HEALTH INSURANCE PROGRAM INTAKE QUESTIONNAIRE 952 kb 09/21/2023 Y