Application For Insurance - North Dakota Workforce Safety And Insurance Page 3
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3APPLICATION FOR INSURANCE (cont’d)
Page 3 of 3
Legal name of entity or individual
Employer’s spouse and/or children coverage
You must list the employer’s spouse and all of the employer’s children under the age of 22 who have received or will receive
compensation from your business. (Additional sheets may be attached)
Coverage for the spouse and children under age 22 is provided by special contract only.
Spouse – the premium is calculated on the wage cap amount.
Children under the age of 22 for payroll period – the premium is based on actual wages.
Children 22 and older for payroll period – wages should be reported along with the other employees.
Coverage becomes effective upon WSI's receipt of a completed, signed elective coverage contract.
Name of family member
Social Security
Date of birth
Relationship
Class code
Estimated wages
Is coverage
number
desired?
Yes
No
Yes
No
SECTION 8 –
Employee activity and estimated 12-month payroll – additional sheets may be attached
Describe each unique type of work performed within the business (e.g., clerical office, janitorial, traveling personnel, etc.) List the number
of employees engaged in that type of work and estimate the payroll which will be expended for each in the next 12 months. If you need
assistance, contact Employer Services for more information at 701-328-3800 or 800-777-5033.
Place where work is performed
Description of work performed
Number of employees
Estimated payroll
(not including owners)
(include room and board allowance)
SECTION 9 –
Temporary and incidental coverage
Extraterritorial coverage – as a general rule, extraterritorial coverage extends to incidental operations lasting fewer than 30 days in a
state where the employer has no other significant contacts with that state and those operations do not require the employer to purchase
workers’ compensation insurance under the laws of that state.
Reciprocal coverage – WSI currently has reciprocal agreements with seven states: Idaho, Montana, Oregon, South Dakota, Utah,
Washington, and Wyoming. These reciprocal agreements allow your ND employees to work in those states on a temporary basis without
purchasing workers’ compensation coverage in that jurisdiction. The reciprocal agreements for each state vary and may include
exclusions. These agreements must be requested by the employer and be approved before becoming effective.
Do you anticipate having any North Dakota based employee(s) that will travel outside ND for work?
Yes
No
Do you intend to cover your ND based employee(s) under your WSI policy while temporarily working outside ND?
Yes
No
If yes, indicate the state(s) your ND based employee(s) will be working.
If no, do you have separate coverage in the state(s) where the employee(s) will be working?
Yes
No
SECTION 10 –
Fraud warning
North Dakota law provides that any employer who willfully misrepresents to WSI the amount of payroll upon which compensation
premium is based is guilty of a Class A misdemeanor. If the premium owing exceeds $500, the employer is guilty of a Class C felony. The
employer is also civilly liable to WSI in the amount of 3 times the difference between the premium paid and the amount that should have
been paid.
I acknowledge that I have read this Fraud Warning and understand that failing to secure workers' compensation coverage, filing a false
payroll report, or willfully misrepresenting the amount of payroll is a criminal offense. I understand that WSI is relying upon the truth of my
statements on this application. I declare that all information entered on this report is true, correct, and accurate.
Signature of owner/officer
Printed name
Date
Title
Telephone number
Email address
SECTION 11 –
Additional information or comments
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