Application For Insurance - North Dakota Workforce Safety And Insurance
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31600 E Century Ave, Ste 1
APPLICATION FOR
PO Box 5585
INSURANCE
Bismarck ND 58506-5585
Telephone 800-777-5033
EMPLOYER SERVICES /
Fax 701-328-3750
PHS DIVISION
TTY (hearing impaired) 800-366-6888
SFN 5556 (05/2016)
Fraud and Safety Hotline 800-243-3331
For WSI use only
Employer account number
Effective date of coverage
Expiration date - payroll period
NAICS
SECTION 1 –
General business information
Legal name of entity or individual
Trade name of business or DBA
(if different from legal name)
Website address
Federal Tax ID
Unemployment account number
First date employee(s) worked or are expected to work in ND
Date operations will begin/began in ND
Attention
Business mailing address (street address)
Suite/apartment
PO Box
City
State
ZIP code
Physical business address, if different than mailing address
Suite/apartment
City
State
ZIP code
Contact information
Contact
(Last name)
(first name)
Title
Email address
Telephone number
Cell phone number
Fax number
North Dakota locations - Provide address of other ND locations if different from the mailing address above. No PO boxes please.
(additional sheets may be attached)
Address
City
State
ZIP code
Telephone number
SECTION 2 –
Third party information
Accountant
(Last name)
(first name)
Telephone number
Email address
Will you be utilizing the services of a Professional Employer Organization (PEO) or employee leasing company?
Yes
No
If yes, please provide their business information
Name
Address
City
State
ZIP code
SECTION 3 –
Reason for applying
Please indicate reason for applying for insurance coverage
New or existing business now requesting workers’ compensation insurance coverage
Change of entity
Form continued on next page. Please submit all pages to WSI.
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Parent category: Legal