Workers Forms

Adult Learning Center Attendance Log (C67)
Capability Assessment Form (C3)
Chemical Exposure Questionnaire (C151)
Dentist Report of Injury (C31)
Dermatitis Questionnaire (C150)
Employer Transitional/Permanent Job Offer (C165)
Employer's Report of Death (C9)
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
Non-Dependent(s) Report of Death (C12)
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)
Spouse/Dependent(s) Report of Death (C8)
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
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