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North Dakota Insurance Department
Adam Hamm, Commissioner
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Below you will find a listing of every state-specific form that applies to Health Insurers under the Company Filing Requirements and Premium Tax Filing Requirements sections of the ND Insurance Department website.

Please refer to the general information under the filing requirements for licensed companies section.

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.

Abstract form:
  • Electronic filing of the company's abstract form is required. Please click on Health Company Abstract of Statement SFN 53892. Microsoft Internet Explorer version 6.0 or greater is required.
  • March 1 is the deadline for submitting the electronic abstract form.
  • A filing fee of $30 is imposed by N.D.C.C. Section 26.1-01-07 and is included on the Renewal Statement SFN 16354 form.
  • Publication fees are imposed under N.D.C.C. Section 26.1-03-10 and N.D.C.C. Section 46-05-03 and are billed directly to the insurance company by the North Dakota Newspaper Association.
  • If amended abstract forms are filed after the March 1 deadline, an additional $30 filing fee and any applicable re-publication fees will be payable.

Please contact the Department if you have difficulty finding 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
800.247.0560 toll free
800.366.6888 TTY line




Health Company Abstract of Statement SFN 53892
https://eforms.nd.gov/lfserver/SFN53892

Health Entities Checklist SFN 52094
http://www.nd.gov/eforms/Doc/sfn52094.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


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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