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North Dakota Insurance Department
Adam Hamm, Commissioner
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Below you will find a listing of every form that applies to county mutual insurance companies under the company filing requirements and premium tax filing requirements sections of this website.

The electronic version of the Annual Statement and the Interim Financial Statement should be filed as an email attachment addressed to ytkeniston@nd.gov.

IMPORTANT: the County Mutual Annual Statement is a fillable Excel spreadsheet. Do not open this file directly but rather download the file to your PC's hard drive. Click on the file below. Select the "Save" or "Save Target As" option. Save the file to a sub-directory on your computer. Once you have saved the file, you can locate the file on your computer Windows Explorer. When opening the file, a pop-up box will ask about updating the file's links, select "Don't Update." A second pop-up box will ask about disabling macros, click "OK." If you have problems using this file, call 701.328.9617.

Renewal Statement For Admitted Companies

The Renewal Statement For Admitted Companies must be submitted using the North Dakota Insurance Department's enhanced Online Renewal System.

The Online Renewal System requires payment of the company's renewal fees by one of the following options:
  • ACH credit - your financial institution or accounting department must originate payment; see the Online Renewal System for further instructions.
  • Wire transfer - see the Online Renewal System for further instructions.
  • Payment by check - a completed copy of the renewal statement must be included along with the company's check and postmarked by March 1 to avoid penalties.
If you have questions regarding the ACH credit or wire transfer processes, please contact Laurie Scully at 701-328-2503 or lscully@nd.gov.

Amendments - Please note that the Online Renewal System is designed to accept only originally filed renewal statements. Amended renewal forms cannot be submitted electronically. They must be mailed to the Department. Contact the Department at 701-328-3328 or insurance@nd.gov if in need of an amended renewal form.

Please contact the Department if you have difficulty finding or accessing a form that you need.

Yvonne Keniston
ytkeniston@nd.gov
North Dakota Insurance Department
State Capitol, fifth floor
Dept. 401
600 E. Boulevard Ave.
Bismarck, ND 58505-0320
701.328.2440
701.328.4880 fax




County Mutual Abstract of Statement SFN 4805
http://www.nd.gov/eforms/Doc/sfn04805.pdf

County Mutual Companies Checklist SFN 53137
http://www.nd.gov/eforms/Doc/sfn53137.pdf

Fire District Reporting Form SFN 52764
http://www.nd.gov/eforms/Doc/sfn52764.pdf

Online Renewal System
https://secure.apps.nd.gov/ins/core/index.aspx

Premium Tax - Estimated Tax Form SFN 11051
http://www.nd.gov/eforms/Doc/sfn11051.pdf

Premium Tax - Reconciled Tax Form SFN 11050
http://www.nd.gov/eforms/Doc/sfn11050.pdf

County mutual annual statement (Excel)
cmannualstatementblank.xls

County mutual annual statement instructions
cmannualstatementinstructions.pdf

County mutual interim financial statement (Excel)
countymutualinterimprinted.xls


North Dakota Insurance Department
600 E. Boulevard Ave.
Bismarck, ND 58505-0320
Phone 701.328.2440
Toll free 800.247.0560
Fax 701.328.4880

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