Forms

Medium
North Dakota State Forms

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 Certification of Exemption to Issue Gift Annuities (SFN 17914)

Application for Coverage (SFN 54369)

Application for Individual Reinsurance Intermediary License (SFN 18556)

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)

Certificate of Assuming Insurer (AR-1) (SFN 53913)

Certificate of Certified Reinsurer (CR-1) (SFN 60995)

Certification as an Insurer of Automobile Warranty Contracts (SFN 54357)

Commercial Blanket Bond Application for Game and Fish Vendors (SFN 58566)

Complaint Questionnaire (SFN 18956)

Complaint Questionnaire - Agent (SFN 19050)

County Mutual Abstract of Statement (SFN 4805)

County Mutual Companies Checklist (SFN 53137)

Continuing Education Course Completion Certificate (SFN 10923)

Data Processing Questionnaire (SFN 4792)

Declaration of Compliance with the Auto Accident Reparations Act (SFN 51663)

Discount Plan Organization Application (SFN 61675)

Employee Suggestion Incentive Program (SFN 19291)

Estimated Premium Tax Statement (SFN 11051)

Fraternal Societies Checklist (SFN 52095)

Health Company Abstract of Statement (SFN 4802)

Health Entities Checklist (SFN 52094)

Individual Health Insurance Data Report (SFN 54182)

Insurance Producer Disclosure Notice - Fees for Insurance Services (SFN 61674)

Issuer Certification (Long-term Care Partnership Program) (SFN 58600)

Joint Underwriter Application (SFN 58427)

Large Group Health Insurance Data Report (SFN 54180)

Life, Accident and Health/Fraternal Insurers Checklist (SFN 52090)

Life Company Abstract of Statement (SFN 4802)

Payment Voucher/Authorization (SFN 52579)

Policy, Form, and Rate Filing Transmittal - ND1000 (SFN 51679)

Premium Finance Application (SFN 16825)

Premium Finance Company Balance Sheet (SFN 16836)

Prescription Connection Intake Application (SFN 58370)

Reconciled Tax Statement (SFN 11050)

Registration of Appointment of Agent for Service of Process (SFN 53916)

Request for Line of Duty Death Benefit (SFN 59127)

Segregated Account/Contents of Contract - Attachment B (SFN 17913)

Small Group Health Insurance Data Report (SFN 54181)

State Health Insurance Counseling (SHIC) Intake Questionnaire (SFN 61886)

Surety Bond for Self-Insurers (SFN 19312)

Title Company Abstract of Statement (SFN 4802)

Title Companies Checklist (SFN 52092)

Uniform Suspected Insurance Fraud Reporting (SFN 58333)

Utilization Review Agent Certification (SFN 18378)

Utilization Review Filing Report (SFN 18332)

Viatical Settlement Provider Individual Statement (SFN 58686)

 

Producer Licensing

Application for Exemption by Automobile Rental Company for Counter Sales Personnel (SFN 52150)

Appointment/Termination (SFN 50291)

Certification of Advertising Compliance (SFN 58799)

Change of Address and/or Name (SFN 50072)

Life Settlement Broker Business Entity Statement (SFN 54042)

Life Settlement Broker Individual Statement (SFN 50502)

Life Settlement Provider Statement (SFN 54043)

Notification by Life Insurance Producer of Action as Life Settlement Broker (SFN 59438)

Portable Electronics Vendor Acknowledgement (SFN 60894)

Request to Change the Designated Responsible Licensed Producer (SFN 60801)

Request for Letter of Clearance (SFN 60808)

Surplus Lines Annual Placement Report (SFN 4824)

Surplus Lines Annual Tax Statement (SFN 17419)

Surplus Lines Certified Diligent Search Statement (SFN 4818)

Surplus Lines Report of Placement (SFN 59883)

Voluntary Cancellation Request or Removal of Line(s) of Authority (SFN 53881)

 

Property & Casualty

Building Application (SFN 16259)

Commercial Roof Questionnaire (SFN 52655)

Consent to Rate Application - NDPC400 (SFN 51683)

Coverage Changes on Current Property Insured (SFN 3380)

Crop Insurance Rate Filing - NDPC200 (SFN 51682)

Fire Insurance Premiums and Losses (SFN 7832)

Loss Prevention Questionnaire (SFN 53166)

Medical Malpractice Claim Report (SFN 17118)

Notice of Claim (SFN 12199)

Notice of Loss (SFN 9576)

Outdoor Property Application (SFN 60515)

Property and Casualty Company Abstract of Statement (SFN 4802)

Property and Casualty Insurers Checklist (SFN 52091)

Prospective Loss Costs Reference Filing - NDPC300 (SFN 51681)

SERFF Retaliatory Filing Fee - ND2000 (SFN 51680)