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Adam Hamm, 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

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

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)

2013ndfiredistreport.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