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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)
  • 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)
  • Medical Service Dispute Resolution Request (M2)
  • Midterm Progress
  • Notice of Legal Representation
  • Personal Reimbursement Appeal (C183)
  • Preferred Worker Registration
  • Prior Dental Questionnaire (C96t)
  • Prior Injury & Pre-Existing Condition Questionnaire (C96a)
  • 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 - 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
  • Third Party Notice of Legal Representation
  • Transitional Job Offer (C165)
  • Vocational Release of Information

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About Us

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

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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. 

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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

 

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