Workers Forms

Adult Learning Center Attendance Log (C67)
Capability Assessment Form (C3)
Chemical Exposure Questionnaire (C151)
Chiropratic Progress/Final Report (C25)
Dentist Report of Injury (C31)
Dermatitis Questionnaire (C150)
Designated Medical Provider Selection
Employment Contact Log
First Report of Injury
Foot and Ankle Questionnaire (C131)
Fraud Report Form
Hearing & Noise Questionnaire (C129)
Hernia Questionnaire (C149)
Independent Exercise Form (C59a)
Independent Exercise Program Log (C59)
Injured Worker Contact (Prior Injury & Pre-Existing Condition Follow-Up) (C96a)
Midterm Progress
Notice of Legal Representation
Preferred Worker Registration
Prior Dental Questionnaire (C96t)
Release of Information (C57b)
Repetitive Motion Questionnaire (C63)
Request for Payment for Home Health Care (C40b)
Request for Personal Reimbursement (C40a)
Return to Work Status/Progress (C97b)
Third Party Notice
Third Party Notice - Slip and Fall Questionnaire
Third Party Notice and Questionnaire
Third Party Notice and Questionnaire - Death
Third Party Notice and Questionnaire - Medical Malpractice
Third Party Notice and Questionnaire - Product Liability
Transitional Job Offer (C165)
Vocational Release of Information

About Us

North Dakota Workforce Safety & Insurance is the sole provider and administrator of the workers’ compensation system in North Dakota.

Reports

Careers

Are you looking for a career where you can provide the best services and solutions to injured workers, employers, and medical facilities? Join our team today.

Fraud Awareness

North Dakota Workforce Safety & Insurance has a responsibility to the employers and employees of North Dakota to investigate all allegations of fraud.

Contact Us

Phone:	800-777-5033
Email:	ndwsi@nd.gov
Address:	1600 E. Century Ave, Ste 1 Bismarck, ND 58503