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North Dakota Insurance Department
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Forms
  Advisory Board Travel Expense Voucher SFN 52864
  Affidavit SFN 4795
  Agent for Service of Process SFN 8330
  Agent of Process - Attachment A SFN 17912
  Annual Statement for an Insurance Premium Finance Company SFN 16824
  Application for a Hobby Boiler License Examination SFN 58785
  Application for a Hobby Boiler License SFN 58784
  Application for Administrator-Certificate of Registration
  Application For Certification of Exemption to Issue Gift Annuities SFN 17914
  Application for Coverage SFN 54369
  Application for Exemption by Automobile Rental Company for Counter Sales Personnel SFN 52150
  Application for Individual Reinsurance Intermediary License - Individual SFN 18556
  Application for Individual Reinsurance Intermediary License SFN 18556
  Application for Non-Resident Insurance Producer License (For Individuals and Business Entities)
  Application for Petroleum Tank Release Compensation Fund SFN 17017
  Application for Pharmacy Benefit Manager (Register as administrator)
  Application for Registration as a Purchasing Group SFN 53914
  Application for Registration as a Risk Retention Group (Foreign) SFN 53915
  Application for Reinsurance Intermediary License - Corporation or Partnership SFN 18739
  Application for Resident Insurance Producer License paper application
For individual or business entities--links appear on the right side
  Appointment/Termination SFN 50291
  Boiler Inspection Report SFN 10706
  Boiler or Water Heater Installation Report SFN 59530
  Building Application SFN 16259
  Certificate of Assuming Insurer AR-1 SFN 53913
  Certification As An Insurer Of Automobile Warranty Contracts SFN 54357
  Certification of Advertising Compliance SFN 58799
  Change of Address/Name SFN 50072
  Commercial Blanket Bond Application for County Game and Fish Vendors SFN 58566
  Commercial Roof Questionnaire SFN 52655
  Complaint Against a Company SFN 18956
  Complaint Against an Agent SFN 19050
  Consent to Rate Application - NDPC400 SFN 51683
  County Mutual Abstract of Statement SFN 4805
  County Mutual Companies Checklist SFN 53137
  Course Completion Certificate SFN 10923
  Coverage Changes on Current Property Insured SFN 3380
  Crop Insurance Rate Filing SFN 51682
Fillable
  Crop Insurance Rate Filing SFN 51682
Printable
  Data Processing Questionnaire SFN 4792
  Declaration of Compliance with the Auto Accident Reparations Act SFN 51663
  Electronic address change
  Electronic Appointment Renewals
  Electronic Non-Resident Insurance Producer License (for Individuals or Business Entities)
  Electronic Non-Resident License Renewal
  Environmental Consultant Expense Worksheet SFN 18731
  Excavation Expenses Worksheet SFN 17331
  Fire District Reporting Form SFN 52764
  Fire Insurance Premiums & Losses SFN 7832
  Fraud Reporting Form SFN 58333
  Fraternal Societies Checklist SFN 52095
  Health Company Abstract of Statement SFN 53892
  Health Entities Checklist SFN 52094
  Hobby Boiler License Affidavit and Application SFN 58786
  Individual Health Insurance Data Report SFN 54182
  Information Required To Insure Radio Towers and Equipment SFN 59018
  Insured Property--Building Improvements SFN 59034
  Large Group Health Insurance Data Report SFN 54180
  Life, Accident and Health Insurers Checklist SFN 52090
  Life Company Abstract of Statement SFN 4803
  Life Settlement Broker Business Entity Statement SFN 54042
  Life Settlement Broker Individual Statement SFN 50502
  Life Settlement Provider Statement SFN 54043
  Loss Prevention Questionnaire SFN 53166
  LTC Partnership Issuer Certification SFN 58600
  Medical Malpractice Claim Report SFN 17118
  Notice of Claim SFN 12199
  Notice of Course Subsequent Offering SFN 10926
  Notice of Loss SFN 9576
  Notification by Life Insurance Producer of Action as Life Settlement Broker SFN 59438
  Outdoor Property Application SFN 60515
  Payment voucher/authorization SFN 52579
  Petroleum Tank Registration SFN 17132
  Policy, Form and Rate Filing Transmittal-ND1000 SFN 51679
  Premium Finance Application SFN 16825
  Premium Finance Company Balance Sheet SFN 16836
  Premium Tax - Estimated Tax Form SFN 11051
  Premium Tax - Reconciled Tax Form SFN 11050
  Prescription Connection Application SFN 58370
  Property and Casualty Company Abstract of Statement SFN 4802
  Property and Casualty Insurers Checklist SFN 52091
  Prospective Loss Costs Reference Filing - NDPC300 - SFN 51681
  Registration of Appointment of Agent for Service of Process SFN 53916
  Renewal of a Hobby Boiler License SFN 60444
  Report of Placement of Surplus Lines Insurance SFN 59883
  Request for Line of Duty Death Benefit SFN 59127
  Sale or Disposal of Petroleum Storage Tanks SFN 50884
  Segregated Account/Contents of Contract - Attachment B SFN 17913
  SERFF Retaliatory Filing Fee - ND2000 - SFN 51680
  Small Group Health Insurance Data Report SFN 54181
  Surety Bond for Self Insurers SFN 19312
  Surplus Line Risks SFN 4824
  Surplus Lines Affidavit SFN 4818
  Surplus Lines Statement Of Taxable Premiums Received On North Dakota Business SFN 17419
  Title Company Abstract of Statement SFN 14755
  Title Companies Checklist SFN 52092
  Uniform Suspected Insurance Fraud Reporting Form
  Utilization Review Agent Certification SFN 18378
  Utilization Review Filing Report SFN 18332
  Viatical Settlement Provider-Individual Statement SFN 58686
  Voluntary Cancellation Insurance Producer License SFN 53881
  W-9 Request for Taxpayer Identification Number and Certification

 
County mutual annual statement (Excel)
cmannualstatementblank.xls

Fire district electronic filing (Excel)
NDFireDistReport.xls

General instructions - company checklists
Generalinstructions.pdf

Paper NAIC business entity renewal application form
naicuniformapplicationforbusinessentityrenewal.pdf

Paper NAIC Uniform Individual License Renewal/Continuation Application
naicuniformapplicationforindividualrenewal.pdf

Uniform Application for Third Party Administrator License/Registration
tpauniformapp.pdf

Voluntary withdrawal guidelines
guidelinesforvoluntarywithdrawals.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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