Jon Godfread, Commissioner
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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
Change the Designated Responsible Licensed Producer SFN 60801
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 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
Portable Electronics Vendor Acknowledgement SFN 60894
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 to Change the Designated Responsible LIC Producer SFN 60801
Request for Letter of Clearance SFN 60808
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
file size: 326 kb
Fire District Electronic Filing (Excel)
General Instructions - Company Checklists
Generalinstructions.pdf
file size: 109 kb
Paper NAIC Business Entity Renewal Application Form
naicuniformapplicationforbusinessentityrenewal.pdf
file size: 400 kb
Paper NAIC Uniform Individual License Renewal/Continuation Application
naicuniformapplicationforindividualrenewal.pdf
file size: 392 kb
Uniform Application for Third Party Administrator License/Registration
tpauniformapp.pdf
file size: 152 kb
Guidelines for Voluntary Withdrawals
file size: 254 kb
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
Copyright © 2018 North Dakota Insurance Department
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