Forms

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Insurance Department - Public Form(s)

SFNTitleSizeDateFillable
3380 Coverage Changes on Current Property Insured 181 kb 01/13/2012
Y
4792 Date Processing Questionnaire 39 kb
Y
4795 Affidavit 167 kb
Y
4805 County Mutual Abstract of Statement 157 kb 11/26/2012
Y
4818 Surplus Line Affidavit 328 kb 06/28/2012
Y
4824 Surplus Line Risks 904 kb 02/09/2012
Y
7832 Fire Insurance Premiums and Losses 231 kb
Y
8330 Agent for Service of Process 205 kb 01/12/2009
Y
9576 Notice of Loss 274 kb 01/20/2012
Y
10706 Boiler Inspection Report 407 kb 01/17/2012
Y
10923 Continuing Education Course Completion Certificate 80 kb
Y
10926 Notice of Subsequent Offering 45 kb
Y
11050 Reconciled Tax Statement 258 kb 01/05/2012
Y
11051 Estimated Tax Form 277 kb 02/29/2012
Y
12199 Notice of Claim 383 kb 08/08/2011
Y
16259 Building Application 519 kb 01/13/2012
Y
16824 Annual Statement for an Insurance Premium Finance Company 107 kb
Y
16825 Premium Finance Application 296 kb
Y
16836 Premium Finance Company Balance Sheet 270 kb
Y
17017 Application for Petroleum Tank Release Compensation Fund 413 kb 11/18/2011
Y
17118 Medical Malpractice Claim Report 145 kb
Y
17132 Petroleum Tank Registration 396 kb 10/11/2012
Y
17331 Excavation Expenses Worksheet 457 kb 04/23/2012
Y
17419 Statement of Taxable Premiums Received on North Dakota Business 388 kb 02/01/2012
Y
17912 Agent of Process-Attachment A 42 kb
Y
17913 Segregated Account/Contents of Contract-Attachment B 28 kb
Y
17914 Application for Certification of Exemption to Issue Gift Annuities 55 kb
Y
18332 Utilization Review Filing Report 273 kb 08/12/2008
Y
18378 Utilization Review Agent Certification 364 kb 02/06/2013
Y
18556 Application for Individual Reinsurance Intermediary License 134 kb
Y
18731 Environmental Consultant Expenses Worksheet 410 kb 09/09/2010
Y
18739 Application for Reinsurance Intermediary License - Corporation or Partnership 128 kb
N
18956 Complaint Questionnaire 231 kb
Y
19050 Complaint Questionnaire - Agent 194 kb
Y
19312 Surety Bond for Self-Insured 317 kb 09/26/2012
Y
50072 Change of Address and/or Name 366 kb 11/26/2012
Y
50291 Appointment /Termination Form 80 kb
N
50502 Viatical Settlement Provider Individual Statement 752 kb 03/15/2010
Y
50884 Sale or Disposal of Petroleum Storage Tanks 352 kb 04/19/2012
Y
51230 Anhydrous Ammonia Storage Facility-Inspection Check List 803 kb 05/12/2008
Y
51231 Anhydrous Ammonia Storage Facility-Inspection Checklist Nurse Tank Inspection Items 174 kb
Y
51232 Anhydrous Ammonia Vessel Pressure Test Report 294 kb 09/07/2010
Y
51663 Declaration of Compliance with Auto Accident Reparations Act 174 kb
Y
51679 Policy, Form, And Rate Filing Transmittal - ND 1000 76 kb
Y
51680 SERFF Retaliatory Filing Fee - ND2000 300 kb 08/12/2011
Y
51681 Prospective Loss Costs Reference Files - NDPC300 301 kb
N
51682 Crop Insurance Rate Filing - NDPC200 350 kb
Y
51682 Crop Insurance Rate Filing - NDPC200 (Printable) 80 kb
N
51683 Consent to Rate Application - NDPC4000 78 kb
Y
52090 Life, Accident, and Health Insurers Checklist 1118 kb 11/20/2012
Y
52091 Property and Casualty Insurers Checklist 1027 kb 11/20/2012
Y
52092 Title Companies Checklist 739 kb 11/28/2012
Y
52094 Health Entities Checklist 912 kb 11/26/2012
Y
52095 Fraternal Societies Checklist 1008 kb 11/28/2012
Y
52150 Application For Exemption By Automobile Rental Company For Counter Sales Personnel 250 kb 11/28/2007
Y
52655 Commercial Roof Questionnaire 498 kb 01/17/2012
Y
52764 Fire District Report 3113 kb 04/12/2013
Y
52864 PTRCF Advisory Board Travel Expense Voucher 512 kb 04/23/2012
Y
53137 County Mutual Companies Checklist 381 kb 11/26/2012
Y
53166 Loss Prevention Questionnaire 533 kb 01/13/2012
Y
53881 Voluntary Cancellation Of Insurance Producer License 224 kb 04/01/2011
Y
53913 Certificate of Assuming Insurer 182 kb
Y
53914 Application for Registration as a Purchasing Group 310 kb 08/21/2007
Y
53915 Application for Registration as a Risk Retention Group (Foreign) 405 kb 11/06/2007
Y
53916 Registration of Appointment of Agent for Service of Process 188 kb
Y
54042 Viatical Settlement Broker Business Entity Statement 461 kb 03/15/2010
Y
54043 Viatical Settlement Provider Statement 699 kb 04/11/2011
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
54357 Certification As An Insurer Of Automobile Warranty Contracts 235 kb 06/02/2009
Y
54369 Application for Coverage 651 kb 05/09/2013
Y
58333 Uniform Suspected Insurance Fraud Reporting 1422 kb 02/21/2008
Y
58370 Prescription Connection Intake Application 696 kb 06/14/2012
Y
58427 Joint Underwriter Application 168 kb
Y
58566 Commercial Blanket Bond Application for County Game and Fish Vendors 326 kb 09/08/2010
Y
58600 Issuer Certification (Long-Term Care Partnership Program) 696 kb 10/04/2007
Y
58686 Viatical Settlement Provider Individual Statement 688 kb 10/22/2007
Y
58784 Application for a Hobby Boiler License 350 kb 08/22/2011
Y
58785 Application for a Hobby Boiler License Examination 347 kb 08/22/2011
Y
58786 Hobby Boiler License Affidavit and Application 296 kb 09/08/2010
Y
58799 Certification of Advertising Compliance 274 kb 01/27/2011
Y
59018 Information Required to Insure Radio Towers and Equipment 203 kb 01/30/2012
Y
59034 Insured Property-Building Improvements 187 kb 01/13/2012
Y
59127 Request for Line of Duty Death Benefit 413 kb 09/21/2011
Y
59438 Notification by Life Insurance Producer of Action as Life Settlement Broker 311 kb 04/19/2012
Y
59530 Boiler or Water Heater Installation Report 542 kb 09/08/2010
N
59883 Report of Placement of Surplus Lines Insurance 557 kb 12/13/2012
Y