Form Sfn 5556 - Application For Insurance printable pdf download

Form Sfn 5556 - Application For Insurance

APPLICATION FOR

1600 EAST CENTURY AVENUE, SUITE 1

PO BOX 5585

INSURANCE

BISMARCK ND 58506-5585

EMPLOYER SERVICES /

Telephone 1-800-777-5033

Fax 701-328-3750

PHS DIVISION

TTY (hearing impaired) 1-800-366-6888

SFN 5556 (07/2014)

Fraud and Safety Hotline 1-800-243-3331

PLEASE TYPE OR PRINT USING BLACK OR BLUE INK

FOR WSI USE ONLY

Effective Date of Coverage

Expiration Date - Payroll Period

Employer Account Number

SIC Code

NAICS

GENERAL INFORMATION

Legal Name of Entity or Individual

Trade Name of Business or DBA

(if different from legal name)

Web Site Address

Federal Employer I.D. Number

Unemployment Account Number

First Date employee(s) worked or are expected to work in ND

Date Operations will begin/began in ND

Will you be utilizing the services of a Professional Employer Organization (PEO) or employee leasing company?

Yes

If yes, please provide their business name :

Will you be using a Temporary Staffing Agency?

Yes

If yes, please provide their business information:

Name

Address

City

State

Zip

Your Mailing Address: (However if you will be utilizing the services of a Professional Employer Organization or employee leasing

company, please provide their mailing address here.)

Attention To

Address

Suite/Apt

PO Box

City

State

Zip

Your Business Address:

Same as mailing address above

Address

Suite/Apt #

PO Box

City

County

State

Zip

North Dakota Locations: Enter address of other North Dakota Locations if different from the Mailing Address above. No PO Boxes

please. (additional sheets may be attached)

Address

City

State

Zip

Phone

Contact Person:

First Name

Middle Initial

Last Name

Title

Phone

Cell Phone

Fax

Form Sfn 5556 - Application For Insurance

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