Forms

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  • Definitions:
    • Internal Forms: Forms used by customers internal to North Dakota State Government.
    • Public Forms: Forms used by the general public or entities external to North Dakota State Government
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Insurance Department - Public Form(s)

SFNTitleSizeDateFillable
4792 DATA PROCESSING QUESTIONNAIRE 900 kb 12/01/2020 Y
4795 AFFIDAVIT 167 kb Y
4805 COUNTY MUTUAL ABSTRACT OF STATEMENT 157 kb 11/26/2012 Y
4818 SURPLUS LINES CERTIFIED DILIGENT SEARCH STATEMENT 913 kb 12/03/2019 Y
4824 SURPLUS LINES ANNUAL PLACEMENT REPORT 677 kb 12/08/2015 Y
7832 FIRE INSURANCE PREMIUMS AND LOSSES 231 kb Y
8330 AGENT FOR SERVICE OF PROCESS 205 kb 01/12/2009 Y
10923 COURSE COMPLETION CERTIFICATE 80 kb Y
11050 RECONCILED PREMIUM TAX STATEMENT 431 kb 12/10/2019 Y
11051 ESTIMATED PREMIUM TAX STATEMENT 309 kb 12/10/2019 Y
16824 ANNUAL STATE. FOR INSURANCE PREM. FINANCE COMPANY 107 kb Y
16825 PREMIUM FINANCE APPLICATION 296 kb Y
16836 PREMIUM FINANCE COMPANY BALANCE SHEET 270 kb Y
17118 MEDICAL MALPRACTICE CLAIM REPORT 287 kb 02/12/2019 Y
17419 SURPLUS LINES ANNUAL TAX STATEMENT 401 kb 11/06/2017 Y
17912 AGENT OF PROCESS-ATTACHMENT A 42 kb Y
17913 SEGREGATED ACCOUNT/CONTENTS OF CONTRACT-ATTACHMENT B 28 kb Y
17914 APPL FOR CERTIFICATE OF EXEMPTION TO ISSUE GIFT ANNUITIES 55 kb Y
18332 UTILIZATION REVIEW FILING REPORT 882 kb 11/01/2017 Y
18378 UTILILIZATION REVIEW AGENT CERTIFICATION 434 kb 07/03/2017 Y
18556 APPLICATION FOR INDIVIDUAL REINSURANCE INTERMEDIARY LICENSE 103 kb 01/29/2018 Y
18739 APP FOR REINSURANCE INTERMEDIARY LICENSE-CORP OR PARTNERSHIP 145 kb 01/29/2018 Y
18956 COMPLAINT QUESTIONNAIRE 231 kb Y
19050 COMPLAINT QUESTIONNAIRE AGENT 194 kb Y
19312 SURETY BOND FOR SELF-INSURERS 317 kb 09/26/2012 Y
50072 CHANGE OF ADDRESS AND/OR NAME 906 kb 06/02/2022 Y
50291 APPOINTMENT/TERMINATION 768 kb 07/28/2020 Y
50502 LIFE SETTLEMENT PROVIDER INDIVIDUAL STATEMENT 752 kb 03/15/2010 Y
51663 DECLARATION OF COMPLIANCE WITH THE AUTO ACCIDENT REPARATIONS 174 kb Y
51681 PROSPECTIVE LOSS COSTS REFERENCE FILING-NDPC300 301 kb N
51682 CROP INSURANCE RATE FILING 350 kb Y
51682 CROP INSURANCE FILING - NDPC200 (PRINTABLE) 80 kb N
51683 CONSENT TO RATE APPLICATION 78 kb Y
52150 APP FOR EXEMPTION BY AUTO RENTAL CO FOR COUNTER SALES PERSON 250 kb 11/28/2007 Y
52579 PAYMENT VOUCHER/AUTHORIZATION 439 kb 10/23/2015 Y
53881 VOLUNTARY CANCELLATION REQUEST OR REMOVAL OF LINES OF AUTHOR 910 kb 02/22/2022 Y
53913 CERTIFICATE OF ASSUMING INSURER (AR-1) 182 kb Y
53914 APPLICATION FOR REGISTRATION AS A PURCHASING GROUP 310 kb 08/21/2007 Y
53915 APP FOR REGISTRATION AS A RISK RETENTION GROUP (FOREIGN) 405 kb 11/06/2007 Y
53916 REGISTRATION OF APPOINTMENT OF AGENT FOR SERVICE OF PROCESS 188 kb Y
54042 LIFE SETTLEMENT BROKER BUSINESS ENTITY STMT 461 kb 03/15/2010 Y
54043 LIFE SETTLEMENT PROVIDER STATEMENT 699 kb 04/11/2011 Y
54180 LARGE GROUP HEALTH INSURANCE DATA REPORT 85 kb Y
54181 SMALL GROUP HEALTH INSURANCE DATA REPORT 77 kb Y
54182 INDIVIDUAL HEALTH INSURANCE DATA REPORT 100 kb Y
54357 CERTIFICATION AS AN INSURER OF AUTOMOBILE WARRANTY CONTRACTS 360 kb 07/25/2013 Y
58333 UNIFORM SUSPECTED INSURANCE FRAUD REPORTING 1422 kb 02/21/2008 Y
58370 PRESCRIPTION CONNECTION INTAKE APPLICATION 1492 kb 08/12/2020 Y
58427 JOINT UNDERWRITER APPLICATION 168 kb Y
58600 ISSUER CERTIFICATION-LTC PARTNERSHIP PROGRAM 696 kb 10/04/2007 Y
58686 VIATICAL SETTLEMENT PROVIDER INDIVIDUAL STATEMENT 688 kb 10/22/2007 Y
58799 CERTIFICATION OF ADVERTISING COMPLIANCE 274 kb 01/27/2011 Y
59127 REQUEST FOR LINE OF DUTY DEATH BENEFIT 413 kb 09/21/2011 Y
59438 NOTIFICATION BY LIFE INS PRODUCER OF LIFE SETTLEMENT BROKER 311 kb 04/19/2012 Y
59883 SURPLUS LINES REPORT OF PLACEMENT 448 kb 06/18/2019 Y
60801 REQUEST TO CHANGE THE DESIGNATED RESPONSIBLE LIC PRODUCER 898 kb 02/22/2022 Y
60808 REQUEST FOR LETTER OF CLEARANCE 404 kb 05/23/2016 Y
60894 PORTABLE ELECTRONICS VENDOR ACKNOWLEDGEMENT 363 kb 08/12/2015 Y
60995 CERTIFICATE OF CERTIFIED REINSURER (CR-1) 623 kb 01/05/2016 Y
61674 INSURANCE PRODUCER DISCLOSURE - FEES FOR INSURANCE SERVICES 896 kb 08/20/2019 Y
61675 DISCOUNT PLAN ORGANIZATION APPLICATION 926 kb 08/21/2019 Y
61702 SURETY BOND OF DISCOUNT PLAN ORGANIZATIONS 953 kb 10/02/2019 Y
61886 STATE HEALTH INSURANCE PROGRAM INTAKE QUESTIONNAIRE 952 kb 09/21/2023 Y
62101 INSURANCE DATA SECURITY CERTIFICATION 29 kb 11/17/2021 Y