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North Dakota Insurance Department
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Below you will find a listing of every form that applies to a registered entity. The annual filing requirements for each type of registered entity are explained under the company licensing section of this website.

Renewal Affidavit for Non-Admitted Companies

The Renewal Affidavit For Non-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:
  • Payment by credit card - note that only Visa, MasterCard or Discover cards are accepted (American Express card is not accepted); 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.


Purchasing group

Application for Registration as a Purchasing Group (SFN 53914)

Registration of Appointment of Agent for Service of Process (SFN 53916)

Online Renewal System

Risk retention group not chartered in North Dakota

Application for Registration as a Risk Retention Group (Foreign) (SFN 53915)

Registration of Appointment of Agent for Service of Process (SFN 53916)

Online Renewal System

Certification as an Insurer of Automobile Warranty Contracts (SFN 54357)

Accredited reinsurer

Certificate of Assuming Insurer AR-1 (SFN 53913)

Online Renewal System

Trusteed reinsurer

Certificate of Assuming Insurer AR-1 (SFN 53913)

Online Renewal System

Surplus lines insurer

Agent for Service of Process (SFN 8330)

Affidavit (SFN 4795)

Data Processing Questionnaire (SFN 4792)

Online Renewal System

Reinsurance intermediary

Application for Individual Reinsurance Intermediary License (SFN 18556)

Application for Reinsurance Intermediary License - Corporation or Partnership (SFN 18739)

Agent for Service of Process (SFN 8330)

Premium finance company

Premium Finance Application (SFN 16825)

Premium Finance Company Balance Sheet (SFN 16836)

Annual Statement for an Insurance Premium Finance Company (SFN 16824)

Charitable gift annuities corporation

Application for Certification of Exemption to Issue Gift Annuities (SFN 17914)

Agent of Process - Attachment A (SFN 17912)

Segregated Account/Contents of Contract - Attachment B (SFN 17913)

Utilization review agent

Utilization Review Agent Certification (SFN 18378)

Utilization Review Filing Report (SFN 18332)




Please review the requirements for your entity under the company licensing section of this website.

If you have questions, or cannot find a form that you need, please contact:

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



Affidavit SFN 4795
http://www.nd.gov/eforms/Doc/sfn04795.pdf

Agent for Service of Process SFN 8330
http://www.nd.gov/eforms/Doc/sfn8330.pdf

Agent of Process - Attachment A SFN 17912
http://www.nd.gov/eforms/Doc/sfn17912.pdf

Annual Statement for an Insurance Premium Finance Company SFN 16824
http://www.nd.gov/eforms/Doc/sfn16824.pdf

Application For Certification of Exemption to Issue Gift Annuities SFN 17914
http://www.nd.gov/eforms/Doc/sfn17914.pdf

Application for Individual Reinsurance Intermediary License - Individual SFN 18556
http://www.nd.gov/eforms/Doc/sfn18556.pdf

Application for Registration as a Purchasing Group SFN 53914
http://www.nd.gov/eforms/Doc/sfn53914.pdf

Application for Registration as a Risk Retention Group (Foreign) SFN 53915
http://www.nd.gov/eforms/Doc/sfn53915.pdf

Application for Reinsurance Intermediary License - Corporation or Partnership SFN 18739
http://www.nd.gov/eforms/Doc/sfn18739.pdf

Certificate of Assuming Insurer AR-1 SFN 53913
http://www.nd.gov/eforms/Doc/sfn53913.pdf

Certification As An Insurer Of Automobile Warranty Contracts SFN 54357
http://www.nd.gov/eforms/Doc/sfn54357.pdf

Premium Finance Application SFN 16825
http://www.nd.gov/eforms/Doc/sfn16825.pdf

Premium Finance Company Balance Sheet SFN 16836
http://www.nd.gov/eforms/Doc/sfn16836.pdf

Registration of Appointment of Agent for Service of Process SFN 53916
http://www.nd.gov/eforms/Doc/sfn53916.pdf

Segregated Account/Contents of Contract - Attachment B SFN 17913
http://www.nd.gov/eforms/Doc/sfn17913.pdf

Utilization Review Agent Certification SFN 18378
http://www.nd.gov/eforms/Doc/sfn18378.pdf

Utilization Review Filing Report SFN 18332
http://www.nd.gov/eforms/Doc/sfn18332.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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