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 OUT OF STATE EMPLOYER EMPLOYER SERVICES / PHS DIVISION SFN 53069 (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 Please list all officer(s), partner(s), and owner(s) of the business Full Name (including middle initial) Title Name of North Dakota Project Zip Code Date of Birth Social Security Number Primary North Dakota Business Contact Start Date End Date North Dakota Requirements for Out of State Employers Any employer whose employment results in significant contacts with North Dakota or hires a North Dakota resident to work in ND, shall acquire coverage with WSI. If your workers’ compensation carrier from your home state extends coverage into North Dakota, you must provide proof of coverage. The exception to this requirement is if your home state has a reciprocal agreement with WSI. If your home state will not provide coverage into ND and you have significant contact within ND, you must secure coverage with WSI. An employer has significant contacts when; any employee earns or would have been expected to earn 25% or more of their gross annual wage or income from that employer for services rendered within ND; or 25% of the employer’s gross annual payroll is payable to employees for services rendered in ND. If you open a workers’ compensation policy with WSI, all payroll generated in ND must be reported. 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 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 It is understood that if my organization does employ any worker, I will notify WSI before any actual work has been performed by any employee. I understand it is unlawful for me to employ workers without securing workers’ compensation insurance coverage. 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 information contained in this verification 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) (Title) day of Acknowledged before me this , In (County) ________. , 20 , . (State) Notary Public P12-2 American LegalNet, Inc. www.FormsWorkFlow.com