N.D. Admin. Code § 45-05-01-06
As a condition to the continuance of a certificate of self-insurance, every self-insurer shall transmit to the commissioner, not later than the first day of March in each year, a copy of its last annual
statement showing consolidated report and profit and loss statement as certified by a certified public accountant or a reputable firm of public accountants. Any self-insurer who fails to comply with this provision will have its certificate of self-insurance canceled.
General Authority: NDCC 26.1-41-05(3)
Law Implemented: NDCC 26.1-41-02(2)
Insurance Commissioner 600 East Boulevard Avenue, Dept. 401 Bismarck, ND 58505
Date Application Received
The undersigned, herein referred to as the applicant, being the owner of one or more motor vehicles, hereby makes application for a certificate of self-insurance. In connection with such application the applicant makes the following declarations, for the purpose of enabling the insurance commissioner to make a finding as to whether the applicant possesses the ability to handle and process claims and make payments of basic no-fault benefits and the liabilities covered by motor vehicle liability insurance as required by a self-insurer under North Dakota Century Code chapter 26.1-41, the North Dakota Auto Accident Reparations Act.
The applicant hereby agrees that if this application be approved, such approval shall be subject to making and maintaining with the commissioner such deposits or bonds as the commissioner may require.
It is further agreed and understood that the commissioner may cancel at any time the applicant's certificate of self-insurance.
Name of Applicant __ Nature of Business __
FEIN # ____________
Address (Principal Office) ____________
1. Are you now operating as a self-insurer? ____
If so, how long? ____________
2. Have you a claim department for investigating and adjusting claims?
If not, how are claims investigated and adjusted? ______
3. Have you set up a reserve fund for accident claims? ________
If so, (a) Under what caption does it appear on your financial statement?
and (b) What basis is used for determining reserve requirements?
If not, how do you determine your outstanding liability?
4. Give the following information concerning accidents in which your vehicles were involved during the past three years.
Accident Years
20____
20____
20____
A. Number of accidents:
Personal injury
Property damage
Total
B. Number of claims:
PERSONAL INJURY
Settled by payment
Settled without payment
Open and pending
Total
PROPERTY DAMAGE
Settled by payment
Settled without payment
Open and pending
Total
Number of accidents for which no claims were made
C. Payments on claims:
Personal injury
Property damage
Total
D. Reserves for pending claims:
Personal injury
Property damage
Total
5. Are any automobile liability judgments open and unsatisfied? ___
If so, how many? __ Total amount involved $ __
Are any other judgments open and unsatisfied? ___
If so, how many? __ Total amount involved $ __
6. Is your company a self-insurer under any other phase of your business?
If so, give particulars ___
7. Describe motor vehicles owned by applicant (in North Dakota) under the following headings:
| Year of Manufacture | Make Vehicle | Type | Model | License Number |
|---|---|---|---|---|
☐ An Individual ☐ A Copartnership ☐ A Corporation
Submitted by _______
With principal offices at _______
Condition at close of business ____, 20___
| Dollars | Cents | ||
|---|---|---|---|
| (1) Cash | (a) On hand | $ _____ | ___ |
| (b) In banks | $ _____ | ___ | |
| (2) Accounts receivable | (a) Current | $ _____ | ___ |
| (b) Slow | $ _____ | ___ | |
| (c) Past due | $ _____ | ___ | |
| (3) Notes receivable | (a) Due within 30 days | $ _____ | ___ |
| (b) Due after 90 days | $ _____ | ___ | |
| (c) Past due | $ _____ | ___ | |
| (4) Inventories | (a) Finished goods | $ _____ | ___ |
| (b) Work in process | $ _____ | ___ | |
| (c) Other | $ _____ | ___ | |
| (5) Other current assets (attach list) | $ _____ | ___ | |
| (6) Fixed assets | Land | $ _____ | ___ |
| Buildings | |||
| Less reserves | $ _____ | ___ | |
| Equipment | |||
| Less reserves | $ _____ | ___ |
Other
| Less reserves | $ _____ | |
|---|---|---|
| Total | $ _____ | |
| (7) Other assets (attach list) | $ _____ | |
| Total Assets | $ _____ |
| (1) Accounts payable trade | (a) Not past due | $ _____ |
|---|---|---|
| (b) Past due | $ _____ | |
| (2) Notes payable trade | (a) To banks | $ _____ |
| (b) To others | $ _____ | |
| (3) Accounts payable others (attach list) | $ _____ | |
| (4) Notes payable others (attach list) | $ _____ | |
| (5) Other liabilities (attach list) | $ _____ | |
| (6) Other reserves (attach list) | $ _____ | |
| Total liabilities | $ _____ |
| (7) Capital stock paid in | (a) Common | $ _____ |
|---|---|---|
| (b) Preferred | $ _____ | |
| (8) If individual (or other), amount of investment | $ _____ | |
| (9) Surplus, earned $ _____ (Paid in or other) | $ _____ | |
| Total net worth | $ _____ | |
| Total liabilities and net worth | $ _____ |
(1) Liability on notes discounted, or sold, accounts pledged or sold, or as guarantor on contracts or other contingent liabilities.
Total contingent liabilities (attach schedule)
$ _____
In lieu of filing in the financial statement above, applicants may attach a copy of their last annual statement showing consolidated report and profit and loss statement as certified by certified public accountant or a reputable firm of public accountants. Said statement to be a part of this application.
Give following additional information:
A. Names and addresses of banks in which company has accounts.
Inventories _____
Plants _____
C. Attach statement of profit and loss to date of balance sheet.
D. When and where incorporated or established _____
E. Are any assets pledged to secure notes, loans or mortgages payable?
F. If you have any notes or accounts receivable or payable from or to officers or stockholders, give details concerning method and terms of payment.
G. List names of officers or partners of company.
H. If foreign entity, or nonresident individual, list agent for service of process.
Witness our hands and seals this _ day of ___, 20_, at ___.
STATE OF
_______ SS.
COUNTY OF
(Official Title) _____
(Official Title) _____
Before me, ____, a notary public in and for said county and state, personally appeared ____, respectively of the above-named
9
(corporation), (partnership), or (proprietorship), and severally acknowledged the execution of the foregoing and swore to the contents thereof this __ day of __, 20______.
Notary Public
My commission expires
FOR DEPARTMENT USE ONLY
Financial ability approved
Date
Chief Examiner
Application approved
Date
Insurance Commissioner
The undersigned, pursuant to North Dakota Century Code chapter 26.1-41, the North Dakota Auto Accident Reparations Act, being the owner of one or more motor vehicles as a condition to the issuance of a certificate of self-insurance, hereby executes this undertaking and agrees as follows:
1. 1. The undersigned will respond in the payment of the minimum security requirements as provided under North Dakota Century Code chapter 26.1-41.
2. 2. The undersigned will promptly and efficiently administer all claims made by injured persons, or their successors, and make payment of no-fault benefits to them resulting from accidental bodily injuries sustained in motor vehicles owned by the undersigned.
3. 3. The undersigned agrees and understands that North Dakota Century Code chapter 26.1-41 imposes an absolute liability at law for payment of basic no-fault benefits as a result of being the owner of motor vehicles.
4. 4. The undersigned agrees that the undersigned and any other person occupying the undersigned's motor vehicle or motor vehicles with the expressed or implied permission of the undersigned shall be insured against loss from the liability imposed by law for damages arising out of the operation of such motor vehicles within the United States of America, its territories or possessions, or Canada, with respect to each such motor vehicle as follows: twenty-five thousand dollars because of bodily injury to or death of one person in any one accident and subject to said limit for one person, fifty thousand dollars because of bodily injury to or death of two or more persons in any one accident, and ten thousand dollars because of injuries to or destruction of property of others in any one accident; and coverage for the protection of such persons who are legally entitled to recover damages from owners or operators of uninsured motor vehicles and hit and run motor vehicles because of bodily injury, sickness or disease, including death, resulting therefrom, in the amount of twenty-five thousand dollars because of bodily injury to or death of one person in any one accident and subject to said limit for one person, fifty thousand dollars because of bodily injury to or death of two or more persons in any one accident.
5. 5. The undersigned will promptly and efficiently administer and make a good-faith disposal of all no-fault benefits, liability, and uninsured motorist claims.
6. 6. The undersigned will perform all other obligations not specifically mentioned herein imposed on a basic no-fault insurer by North Dakota Century Code chapter 26.1-41.
7. 7. That any breach of this undertaking, or of the conditions imposed by North Dakota Century Code chapter 26.1-41, will result in the cancellation of the undersigned's certificate of self-insurance.
8. 8. This undertaking shall bind not only the undersigned, but the undersigned's successors, survivors, assigns, and legal representatives.
Witness our hands and seals this __ day of __, 20___, at
(Official Title)
(Official Title)
STATE OF SS.
COUNTY OF
Before me, , a notary public in and for said county and state, personally appeared , respectively, of the above-named (corporation), (partnership), or (proprietorship), and severally acknowledged the execution of the foregoing and swore to the contents thereof this day of , 20 .
Notary Public
My commission expires .
FOR DEPARTMENT USE ONLY
Undertaking approved
Dat e
Chief Examiner
Undertaking approved
Dat e
Insurance Commissioner
History: Amended effective October 1, 1984.