Form Sfn 5556 - Application For Insurance
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1
2500 EAST FRONT AVENUE
APPLICATION FOR INSURANCE
NDWC HelpLine
BISMARCK ND 58504-5685
1-800-777-5033
ND WORKERS COMPENSATION
TELEPHONE NUMBER (701) 328-3800
Questions? Call us. Report Injuries Immediately.
POLICYHOLDER SERVICES DIVISION
FAX NUMBER (701) 328-3750
ND Fraud and Safety Hotline
SFN 5556 (05/2002)
TDD NUMBER (for the hearing impaired only)
1-800-243-3331
(701) 328-3786
Report Fraud and Unsafe Work Conditions.
PLEASE TYPE OR PRINT USING BLACK OR BLUE INK
PAGE 1 OF 2
SHADED AREA FOR NDWC USE ONLY
Employer Account Number
Effective Date of Coverage
Expiration Date - Payroll Period
SIC Code
BUSINESS INFORMATION FOR PRIMARY NORTH DAKOTA LOCATION:
Name of Employer/Insured
Corporate, Legal, or Owner’s Name:
Street Address
Federal Employer I.D. Number:
City
State
Zip Code
Business Phone
Cell Phone
Home Phone
Employer Web Address
Date operations will begin/began in ND (MM/DD/YYYY)
Date will first employ workers in ND (MM/DD/YY)
IF PRINCIPAL PLACE OF BUSINESS IS OTHER THAN NORTH DAKOTA:
Contact Person
Contact Person’s E-mail Address
Address
Contact Person’s Phone Number
City
State
Zip Code
Preferred Mailing Address for Correspondence:
Application Process
Primary ND Location
Principal Place of Business
New Business
Change in Ownership
Type of Ownership:
Individual
General Partnership
Limited Partnership
Limited Liability Partnership (LLP)
Corporation
Cooperative
Nonprofit corporation
Association
Limited Liability Company (LLC)
Government
Other (Explain)
Type of Business:
Healthcare
Contractor (Construction)
Manufacturing
Utility
Transportation
Communication
Wholesale
Retail
Service
Agriculture
Independent Contractor
Other
Business Activity: List the principal products or activities of your firm. Following each item, list the percentage of sales value or receipts
received from the product or activity: i.e., retail men’s clothing or construction-homes.
%
%
%
%
LIST ANY ADDITIONAL NORTH DAKOTA BUSINESS LOCATIONS OTHER THAN THE PRIMARY LOCATION IDENTIFIED ABOVE:
(additional sheets may be attached)
Street Address
City
State
Zip Code
Phone
NAME(S) OF OWNER (AND SPOUSE), PARTNERS, CORPORATE OFFICERS: (additional sheets may be attached)
NAME
ADDRESS
TITLE
HOME PHONE
SOC. SEC. NO.
% OWNED
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Parent category: Business