Home : Forms Below, you will find links to every form located on the North Dakota Insurance Department website. Tip: To quickly locate the form you are looking for, press Ctrl+F and type the form number or name into the find field. If you cannot find what you are looking for, please contact us. 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 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 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 Fraternal Societies Checklist SFN 52095 Fraud Reporting Form SFN 58333 General instructions - company checklists 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 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 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 Notification by Life Insurance Producer of Action as Life Settlement Broker SFN 59438 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 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 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 Provider-Individual Statement SFN 58686 Voluntary Cancellation Insurance Producer License SFN 53881 W-9 Request for Taxpayer Identification Number and Certification Documents County mutual annual statement File Size: 318.5 kb Fillable Excel spreadsheet Fire district electronic filing (Excel) File Size: 139.5 kb Paper NAIC business entity renewal application form File Size: 391.2 kb Note: The recently-mailed renewal notice incorrectly stated the fee. The TPA renewal fee is $50. Paper NAIC Uniform Individual License Renewal/Continuation Application File Size: 383.7 kb Uniform Application for Third Party Administrator License/Registration File Size: 149.2 kb Voluntary withdrawal guidelines File Size: 440.42 kb

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