FormsNorth Dakota Insurance Department - ND 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the name of your Discount Plan Organization and its mailing address, including city, state, and ZIP code.
3. If your principal place of business differs from the mailing address, provide that information as well.
4. Fill in the web address and any DBA (Doing Business As) name if applicable.
5. Indicate the states where your organization operates and provide your Federal Identification Number.
6. Enter the date of incorporation or organization along with the name and mailing address of the parent company.
7. Answer the general interrogatories regarding any past licenses or bankruptcy status by selecting 'Yes' or 'No'.
8. List all officers and directors, including their names, addresses, titles, and occupations. If more space is needed, attach additional pages.
9. Designate a compliance officer by providing their name, address, title, and occupation.
10. Ensure you have attached all required documents as listed at the end of the form before submitting.

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