Home : Forms 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

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