Application For Insurance - North Dakota Workforce Safety And Insurance Page 2
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3APPLICATION FOR INSURANCE (cont’d)
Page 2 of 3
Legal name of entity or individual
SECTION 4 –
Change of entity
If you have indicated a change of entity, please indicate your change below
Purchase
Reorganization
Merger
Other
Complete if applicable
Date of acquisition
What percent of the business did you acquire?
Prior business name
Prior business address
City
State
ZIP code
Prior owner’s name(s)
Prior workers’ compensation account number (if known)
SECTION 5 –
Type of entity
Choose the entity type that most closely describes your business
Individual
Cooperative
General Partnership
Limited Partnership
Limited Liability Partnership
Association
Limited Liability Company
Government
Corporation
Nonprofit Corporation
Sub-S Corporation
Complete if entity is an out-of-state corporation or an out-of-state cooperative
State of incorporation
Date of incorporation
SECTION 6 –
Parent company – compete following section if entity has a parent company. If not, skip to section 7.
Federal Tax ID
Business name
Business address
City
State
ZIP code
Contact person
Contact telephone number
Effective date
Expiration date
Legal name of officer(s) of parent company
Name
Title
Home address, city, state,
Home telephone
Social Security
Is coverage
ZIP code
number
number
desired
Yes
No
Yes
No
Yes
No
Yes
No
SECTION 7 –
Legal name of owners, partners, corporate officers
Name
Title
Home address, city, state,
Home telephone
Social Security
Is coverage
ZIP code
number
number
desired
Yes
No
Yes
No
Yes
No
Yes
No
Form continued on next page. Please submit all pages to WSI.
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