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North Dakota Insurance Department
Adam Hamm, Commissioner
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All carriers writing hospital, surgical and medical expense and major medical business in the individual, small group and large group markets in North Dakota are required by law to submit annual data report forms [N.D.C.C. 26.1-36.4-06(3) & N.D. Admin. Code 45-06-06.1-11].

Please complete the forms below and return them to the Department no later than March 15. If a form is not applicable, no submission is required. Companies with zero business to report are not required to file these forms.

Small group annual actuarial certifications must also be received on March 15. The certification must be filed as a rate filing and must address all aspects of N.D.C.C. 26.1-36.3-04(2). Please note also that there is a substantial penalty for small group data forms received after March 15.

Please address all questions and forms to:

Chrystal Bartuska
cabartuska@nd.gov
North Dakota Insurance Department
State Capitol, fifth floor
600 E. Boulevard Ave.
Bismarck, ND 58505
701.328.2440
701.328.4880 fax



Individual Health Insurance Data Report SFN 54182

Large Group Health Insurance Data Report SFN 54180

Small Group Health Insurance Data Report SFN 54181



Companies with zero business to report are not required to file these forms.

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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