1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 Telephone 1-800-777-5033 Fax 701-328-3750 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com VERIFICATION OF NON-EMPLOYMENT NORTH DAKOTA EMPLOYER EMPLOYER SERVICES / PHS DIVISION SFN 53068 (04/09) Name SSN Business Federal ID# Business Name as Registered in North Dakota Type of Ownership Individual Limited Liability Partnership (LLP) Address Business Address Partnership Limited Liability Corporation (LLC) Corporation Other: Business Phone City State Zip Code Type of Work Performed Please list all officer(s), partner(s), and owner(s) of the business Full Name (including middle initial) Title Date of Birth Social Security Number Check all that apply My organization currently does not employ any workers as defined under NDCC 65-01-05 (16) and has not employed workers since __________. It is understood that if my business does employ any worker(s) in the future, I will comply with North Dakota law and obtain workers’ compensation insurance coverage prior to employing workers. I have NEVER employed or hired workers in North Dakota. Acknowledgement I understand it is unlawful for me to employ workers without securing workers’ compensation insurance coverage prior to hiring. I understand that failure to comply with the requirements of the North Dakota Workers’ Compensation act (NDCC 65-04-33) may subject me to criminal, injunctive, and monetary penalties. I certify that the provided information is true and correct to the best of my knowledge. I further certify if any of the representations I have made to WSI change, I am obligated to contact WSI with accurate and current information. Dated this ____ day of (Signature) P12 P12 _______________ , ______. (Title) American LegalNet, Inc. www.FormsWorkFlow.com