ND WSI Insurance Application Form free printable template

WorkforceSafety. com APPLICATION FOR INSURANCE EMPLOYER SERVICES / PHS DIVISION SFN 5556 092008 PLEASE TYPE OR PRINT USING BLACK OR BLUE INK FOR WSI USE ONLY Employer Account Number Effective Date of Coverage Expiration Date - Payroll Period GENERAL INFORMATION Legal Name of Entity or Individual SIC Code NAICS Trade Name of Business or DBA if different from legal name Web Site Address Federal Employer I. Place Where Work Is Performed Description of Work Estimated payroll include Performed...

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How to fill out ND WSI Insurance Application Form

1. Gather necessary documents: Collect all relevant personal and business information needed for the application.
2. Start the form: Access the ND WSI Insurance Application Form either online or as a physical copy.
3. Fill out basic information: Provide your name, address, and contact details at the beginning of the form.
4. Enter business details: If applicable, include your business name, type, and any additional relevant operational information.
5. Detail the type of coverage needed: Specify the type of workers' compensation coverage required based on your industry.
6. Include employee information: List the number of employees and their respective job classifications.
7. Review and sign: Carefully review all filled-out information for accuracy and sign the form.
8. Submit the application: Send the completed application to the appropriate ND WSI office via email or postal service.

Who needs ND WSI Insurance Application Form?

1. Businesses operating in North Dakota that employ workers and require workers' compensation insurance.
2. Employers who need to comply with North Dakota state laws regarding worker injury protection.
3. Startups and employers of independent contractors in the state looking for coverage.

Video instructions and help with filling out and completing safety workforce employee

Instructions and Help about form online workforce

Hi good afternoon and welcome to the screencast today's subjects is going to be the CMS 1500 we're going to be completing it on the patient Isabel Durand if you would turn in your books to job 4.5 4-5 on page 95 it states Isabel Durand arrives for appointment several minutes later she begins having severe chest pains and trouble breathing another worker immediately takes miss Duran to an exam room in a wheelchair will you inform Dr. Heath he tells you to call the hospital for an ambulance while he performs an EKG it shows Mr Rand is having atrial fib the end is taken to the hospital to be admitted complete miss Durant's ledger card in the day sheet charging her only for the EKG most insurance plans would not pay for the office visit in the hospital visit on the same day since the hospital admission will entail a more comprehensive workup by the physician this procedure will be the one charge to the patient rather than a brief office visit the hospital admission charge will be put through the board day sheet at a later time no receipt is needed at this time because the claim will be sent to the insurance carrier by the medical office assistant okay so let's pull out your CMS 1500 the first block we're going to complete is also you need besides the CMS 1500 you're going to meet need Isabel Duran's ledger card so using her ledger card we're going to see that her insurance is Medicare, so we're going to mark the Medicare block 1 her ID number which is block 1a is again on the ledger card is $9.99 six two one three two Diaz and dog now we're going to type in her name by the way anything that you complete on the CMS 1500 should be in capital letters no punctuation marks no commas no hyphens no periods ok Durand Isabel patience date of birth is Oh 5:30, and we're going to put in now they require it's for night you have to put in the complete year so 1944 she's a female the insurers name will put Durand Isabelle then ensures address city zip code telephone all we have to do is put same in here and that will carry all the way down to the telephone number her address is one five seven two one spring way city Douglasville New York zip code Oh 1 2 3 4 telephone number 1 2 3 4 5 7 16 21 she is single she does have another as you will see being my Medicare she has a secondary insurance, and it's since she's low-income its Medicaid or medical assistance, so we go down to a 7 or 11 D as in dog and say yes check then we have to it says if yes returned to complete items 9 a through D we're to go up here we put Durand Isabel the other policy number is 9 9 14 8 2 1-3 again we have Oh 5:30 1944 female, and we want to mark Medicaid down here in Block 9d, and you could either put signature on file or on file, so we're going to put OF and OF over in third block 13 signature on file meaning that you do actually have to keep that signature on file and in case the insurance companies didn't want to audit to make sure that you do have a signature for billing purposes the...

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What is ND WSI Insurance Application Form?

The ND WSI Insurance Application Form is a document used to apply for workers' compensation insurance in North Dakota. It collects essential information from employers to assess their coverage needs.

Who is required to file ND WSI Insurance Application Form?

Employers in North Dakota who are required to provide workers' compensation coverage for their employees must file the ND WSI Insurance Application Form.

How to fill out ND WSI Insurance Application Form?

To fill out the ND WSI Insurance Application Form, employers must provide their business details, such as the name, address, and type of business, along with information about their employees and the nature of the work performed.

What is the purpose of ND WSI Insurance Application Form?

The purpose of the ND WSI Insurance Application Form is to initiate the process of obtaining workers' compensation insurance coverage for employees, ensuring that businesses comply with state laws.

What information must be reported on ND WSI Insurance Application Form?

The ND WSI Insurance Application Form requires reporting information such as the employer's business name, address, contact information, ownership structure, nature of business activities, estimated payroll, and the number of employees.