County Mutual Insurers

Below you will find a listing of every form that applies to county mutual insurance companies under Financial Reporting and Tax Requirements section of the North Dakota Insurance Department website. Please refer to the general information under the Filing Requirements for Licensed Companies section.

Renewal Statement for Admitted Companies

The Renewal Statement for Admitted Companies must be submitted using the North Dakota Insurance Department's enhanced Online Renewal System.

The Online Renewal System requires payment of the company's renewal fees by one of the following options:

  • ACH credit - your financial institution or accounting department must originate payment; see the Online Renewal System for further instructions.
  • Wire transfer - see the Online Renewal System for further instructions.
  • Payment by check - a completed copy of the renewal statement must be included along with the company's check and postmarked by March 1 to avoid penalties.

If you have questions regarding the ACH credit or wire transfer processes, please contact the Department.

Please note that the Online Renewal System is designed to accept only originally filed renewal statements. Amended renewal forms cannot be submitted electronically. They must be mailed to the Department. Please contact the Department if you need an amended renewal form.

Forms

County Mutual Abstract of Statement (SFN 4805)

County Mutual Annual Statement

  • An electronic version of the County Mutual Annual Statement should be filed as an email attachment addressed to colicexam@nd.gov.
  • The County Mutual Annual Statement is a fillable Excel spreadsheet. Do not open this file directly but rather download the file to your computer. Click on the file below. Select the "Save" or "Save Target As" option. Save the file to your computer. When opening the file, a pop-up box will ask about updating the file's links, select "Don't Update." A second pop-up box will ask about disabling macros, click "OK." If you have problems using this file, please contact the Department.

County Mutual Annual Statement Instructions

County Mutual Companies Checklist (SFN 53137)

County Mutual Interim Financial Statement

  • An electronic version of the County Mutual Interim Financial Statement should be filed as an email attachment addressed to colicexam@nd.gov.

Estimated Premium Tax Statement (SFN 11051)

Fire District Report (SFN 52764)

Reconciled Tax Statement (SFN 11050)