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North Dakota Insurance Department
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Below, you will find links to every form located on the North Dakota Insurance Department website. If you cannot find what you are looking for, please contact us.

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


Links
Advisory Board Travel Expense Voucher SFN 52864
Affidavit SFN 4795
Agent for Service of Process SFN 8330
Agent of Process - Attachment A SFN 17912
Anhydrous Ammonia Storage Facility - Inspection Checklist - Nurse Tank Inspection Items SFN 51231
Anhydrous Ammonia Storage Facility Inspection Checklist SFN 51230
Annual Statement for an Insurance Premium Finance Company SFN 16824
Application for Administrator-Certificate of Registration SFN 16853
Application For Certification of Exemption to Issue Gift Annuities SFN 17914
Application for Continuing Education Insurance Course SFN 10920
Application for Continuing Education Provider Coordinator SFN 10921
Application for Coverage SFN 54369
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) SFN 16853
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
Appointment / Termination SFN 50291
Boiler Inspection Report SFN 10706
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 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
Fraternal Societies Checklist SFN 52095
Fraud Reporting Form SFN 58333
Health Company Abstract of Statement SFN 53892
Health Entities Checklist SFN 52094
Individual Health Insurance Data Report SFN 54182
Large Group Health Insurance Data Report SFN 54180
Life Company Abstract of Statement SFN 4803
Life, Accident and Health Insurers Checklist SFN 52090
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
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 Affidavit for Non-admitted Companies SFN 53446
Renewal Statement SFN 16354
Request for Line of Duty Death Benefit SFN 59127
Segregated Account/Contents of Contract - Attachment B SFN 17913
SERFF Retaliatory Filing Fee - ND2000 - SFN 51680
Small Group Health Insurance Data Report SFN 54181
Statement of Basket Clause Investments SFN 53144
Surplus Line Risks SFN 4824
Surplus Lines Affidavit SFN 4818
Surplus Lines Statement Of Taxable Premiums Received On North Dakota Business SFN 17419
Title Companies Checklist SFN 52092
Title Company Abstract of Statement SFN 14755
Uniform Suspected Insurance Fraud Reporting Form
Utilization Review Agent Certification SFN 18378
Utilization Review Filing Report SFN 18332
Viatical Settlement Broker Business Entity Statement SFN 54042
Viatical Settlement Broker Individual Statement SFN 50502
Viatical Settlement Provider Statement SFN 54043
Viatical Settlement Provider-Individual Statement SFN 58686
W-9 Request for Taxpayer Identification Number and Certification
Documents
County mutual annual statement
File Size: 164.5 kb
Fillable Excel spreadsheet
Fire district electronic filing (Excel)
File Size: 136 kb
Paper NAIC Uniform Individual Producer License Renewal/Continuation Application
File Size: 135.5 kb
Voluntary withdrawal guidelines
File Size: 80.59 kb