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Get ND WSI Insurance Application Form

Ame of Entity or Individual NAME(S) OF OWNERS, PARTNERS, CORPORATE OFFICERS Name Title Address Home Phone Soc. Sec. No. % Owned Is Coverage Desired? Yes No Yes No Yes No Yes No EMPLOYER(S) OPTIONAL COVERAGE: (additional sheets may be attached) Coverage for the owner, partner or corporate officers of a business corporation is optional. Check coverage boxes above, if coverage is desired. An employer electing optional coverage will be charged an annual premium based upon the maximum tax.

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