Here, you can find all forms needed for reporting to the Department.
Licensed companies should read the general information under the Filing Requirements for Licensed Companies section.
When filing, please use 8.5" x 11" (letter-sized) paper.
The Renewal Statement for Admitted Companies must be submitted using OPTins.
County Mutual
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.
- Please note the change in the publishing process for the Abstract of Statement per Bulletin 2024-1.
County Mutual Annual Statement Instructions
County Mutual Companies Checklist
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.
Fraternal Societies
Life, Accident and Health/Fraternal Insurers Checklist
Insurance Data Security Certification (SFN 62101)
Please note the change in the publishing process for the Abstract of Statement per Bulletin 2024-1.
Health
Company Abstract of Statement (SFN 4802)
- Electronic filing of the company's abstract form is required.
- March 1 is the deadline for submitting the electronic abstract form.
- A filing fee of $30 is imposed by N.D.C.C. § 26.1-01-07.
- Publication fees are imposed under N.D.C.C. § 26.1-03-10 and N.D.C.C. § 46-05-03 and are billed directly to the insurance company by the North Dakota Newspaper Association.
- If amended abstract forms are filed after the March 1 deadline, an additional $30 filing fee and any applicable re-publication fees will be payable.
- Please note the change in the publishing process for the Abstract of Statement per Bulletin 2024-1.
Life, Accident & Health
Company Abstract of Statement (SFN 4802)
- Electronic filing of the company's abstract form is required.
- March 1 is the deadline for submitting the electronic abstract form.
- A filing fee of $30 is imposed by N.D.C.C. § 26.1-01-07.
- Publication fees are imposed under N.D.C.C. § 26.1-03-10 and N.D.C.C. § 46-05-03 and are billed directly to the insurance company by the North Dakota Newspaper Association.
- If amended abstract forms are filed after the March 1 deadline, an additional $30 filing fee and any applicable re-publication fees will be payable.
- Please note the change in the publishing process for the Abstract of Statement per Bulletin 2024-1.
Property & Casualty
The North Dakota Insurance Department will mail the amended pages for the Fire District Boundary Maps to any foreign property and casualty insurer that does not have the ability to download the map from this website.
Company Abstract of Statement (SFN 4802)
- Electronic filing of the company's abstract form is required.
- March 1 is the deadline for submitting the electronic abstract form.
- A filing fee of $30 is imposed by N.D.C.C. § 26.1-01-07.
- Publication fees are imposed under N.D.C.C. § 26.1-03-10 and N.D.C.C. § 46-05-03 and are billed directly to the insurance company by the North Dakota Newspaper Association.
- If amended abstract forms are filed after the March 1 deadline, an additional $30 filing fee and any applicable re-publication fees will be payable.
- Please note the change in the publishing process for the Abstract of Statement per Bulletin 2024-1.
Property and Casualty Insurers Checklist
Certification as an Insurer of Automobile Warranty Contracts (SFN 54357)
Declaration of Compliance with the Auto Accident Reparations Act (SFN 51663)
Registered & Other Entities
Purchasing Group
Application for Registration as a Purchasing Group (SFN 53914)
Registration of Appointment of Agent for Service of Process (SFN 53916)
Risk Retention Group Not Chartered in North Dakota
Application for Registration as a Risk Retention Group (Foreign) (SFN 53915)
Registration of Appointment of Agent for Service of Process (SFN 53916)
Certification as an Insurer of Automobile Warranty Contracts (SFN 54357)
Accredited Reinsurer
Certificate of Assuming Insurer (AR-1) (SFN 53913)
Trusteed Reinsurer
Certificate of Assuming Insurer (AR-1) (SFN 53913)
Surplus Lines Insurer
Agent for Service of Process (SFN 8330)
Data Processing Questionnaire (SFN 4792)
Reinsurance Intermediary
Application for Individual Reinsurance Intermediary License (SFN 18556)
Application for Reinsurance Intermediary License - Corporation or Partnership (SFN 18739)
Agent for Service of Process (SFN 8330)
Premium Finance Company
Premium Finance Application (SFN 16825)
Premium Finance Company Balance Sheet (SFN 16836)
Annual Statement for an Insurance Premium Finance Company (SFN 16824)
Charitable Gift Annuities Corporation
Application for Certification of Exemption to Issue Gift Annuities (SFN 17914)
Agent of Process - Attachment A (SFN 17912)
Segregated Account/Contents of Contract - Attachment B (SFN 17913)
Utilization Review Agent
Utilization Review Agent Certification (SFN 18378)
Utilization Review Filing Report (SFN 18332)
Please review the requirements for your entity under the Company Licensing section of this website.
Title
Company Abstract of Statement (SFN 4802)
- Electronic filing of the company's abstract form is required.
- March 1 is the deadline for submitting the electronic abstract form.
- A filing fee of $30 is imposed by N.D.C.C. § 26.1-01-07.
- Publication fees are imposed under N.D.C.C. § 26.1-03-10 and N.D.C.C. § 46-05-03 and are billed directly to the insurance company by the North Dakota Newspaper Association.
- If amended abstract forms are filed after the March 1 deadline, an additional $30 filing fee and any applicable re-publication fees will be payable.
- Please note the change in the publishing process for the Abstract of Statement per Bulletin 2024-1.