Form Sfn 5556 - Application For Insurance printable pdf download

APPLICATION FOR INSURANCE

500 EAST FRONT AVENUE

WCB Help

WCB

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BISMARCK ND 58504-5685

1-800-777-5033

TELEPHONE NUMBER (701) 328-3811

Questions? Call us. Report Injuries Immediately.

WORKERS COMPENSATION BUREAU

FAX NUMBER (701) 328-3750

ND Fraud and Safety Hotline

TDD NUMBER (for the hearing impaired only)

POLICYHOLDER SERVICES DIVISION

1-800-243-3331

(701) 328-3786

SFN 5556 (8/00)

Report Fraud and Unsafe Work Conditions.

SHADED AREA FOR BUREAU USE ONLY

Employer Account Number

County Code

Audit District

Inspection District

Effective Date of Coverage

Expiration Date - Payroll Period

Business Name:

Corporate, Legal, or Owner’s Name:

Principle North Dakota Location:

Business Phone:

Home Phone:

___________________________________________________________________________________

Street

Federal Employer I.D. Number:

Employer e-mail address

___________________________________________________________________________________

City

County

State

Zip

Type of Ownership:

North Dakota Mailing Address (If different than above):

r Individual

r General Partnership

___________________________________________________________________________________

Street

r Limited Partnership

r Limited Liability Partnership (LLP)

___________________________________________________________________________________

r Corporation

City

County

State

Zip

r Nonprofit Corporation

If Principle Place of Business is Other Than North Dakota:

r Limited Liability Company (LLC)

r Cooperative

___________________________________________________________________________________

Contact Person

Street

r Association

r Government

___________________________________________________________________________________

r Other (Explain) _________________________________

City

County

State

Zip

Application Process:

r New Business

r Change in Ownership

Date operations will begin/began in ND

:_________________________________

Date first employed workers in ND

:_____________________________________

Month

Day

Year

Month

Day

Year

NAME(S) OF OWNER (AND SPOUSE), PARTNERS, CORPORATE OFFICERS.

NAME(S) OF

OWNER (AND SPOUSE), PARTNERS, CORPORATE OFFICERS.

NAME

ADDRESS

TITLE

HOME PHONE

SOC. SEC. NO.

% OWNED

THE BUREAU MUST BE NOTIFIED IMMEDIATELY OF ANY CHANGES IN OPERATIONS, OWNERSHIP, PARTNERS, OR CORPORATE OFFICERS

EMPLOYER(S) COVERAGE: Coverage for the owner, partner, or corporate officers of a business corporation is optional.

Coverage for the owner, partner, or corporate officers of a business corporation is optional. List the names of

these individuals(s) if optional coverage is desired. An employer electing optional coverage will be charged an annual premium based upon the

maximum taxable payroll cap. Coverage becomes effective upon the Bureau’s receipt of a completed, signed optional coverage contract.

NAME

TITLE

SOC. SEC. NO.

% OWNED

IS COVERAGE DESIRED?

Yes

EMPLOYER’S SPOUSE AND/OR CHILDREN: You must list the spouse, and all children under the age of 22 of the employer (s) who receive

compensation from your business. Coverage is provided only by special contract.

Coverage is provided only by special contract. An employer electing optional coverage for a spouse, or child

under the age of 22, will be charged an annual premium based upon the maximum taxable payroll cap. Coverage becomes effective upon the

Bureau’s receipt of a completed, signed optional coverage contract.

NAME

SOC. SEC. NO.

RELATIONSHIP

CHILD’S DATE OF BIRTH

IS COVERAGE DESIRED?

Yes

Form Sfn 5556 - Application For Insurance

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