Employment Verification Form Montana Employees Working Solely In North Dakota 2015 printable pdf download

WORKERS’ COMPENSATION REGULATION BUREAU

PO Box 8011, Helena MT 59604-8011

406-444-6532

EMPLOYMENT VERIFICATION FORM

MONTANA EMPLOYEES WORKING SOLELY IN NORTH DAKOTA

PLEASE READ BELOW BEFORE COMPLETING THIS FORM:

The Montana Workers’ Compensation Act contains definitions and coverage requirements pertaining to residents of Montana and non-

residents. The workers covered by a Montana workers’ compensation policy are defined by Section 39-71-118, MCA.

Effective July 1, 2015, Montana employees employed by Montana employers who work solely in North Dakota and are required to be covered

in North Dakota are not required to be covered in Montana as long as those employees are covered under a policy in North Dakota. "Work

solely in North Dakota" means the employee does not perform job duties in Montana and coverage is required by the state of North Dakota.

Travel that is commuting to and from a job site in North Dakota from a location in Montana does not constitute performing job duties in

Montana even if the employer pays for all or a portion of the costs of travel or if the worker is paid for the travel time. The Montana workers’

compensation insurer may require proof of coverage in North Dakota and records of work in North Dakota.

PLEASE COMPLETE THIS FORM ATTESTING TO YOUR NORTH DAKOTA COVERAGE AS REQUIRED BY YOUR MONTANA WORKERS’

COMPENSATION INSURER. IT WILL ASSIST YOUR MONTANA INSURER WITH DECISIONS ON PREMIUM AND/OR CLAIMS. IF YOU HAVE

QUESTIONS, CONTACT YOUR MONTANA INSURER OR THE MONTANA DEPARTMENT OF LABOR AND INDUSTRY AT 406-444-6532.

_ _________________________________________________________

MONTANA EMPLOYER’S BUSINESS NAME:

______________________________________________

FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN):

____________________________

_______________________

Employer Address:

C ity and State:

Z ip Code: ___________

________________________________

_______________________

Employer Email Address:

E mployer Phone Number:

________________________________

_______________________

Name of Individual Completing this Form:

Title:

_______________________

Phone Number:

__________________________________________

NAME OF MONTANA WORKERS’ COMPENSATION INSURER:

___________________________

__________________________________

Montana Policy Number:

Insurer Address:

_________________________

City and State:

Z ip Code: ___________ Insurer Phone Number: ______________________

_______________________________________

NORTH DAKOTA POLICY NUMBER:

_ _____________________________________________

Location of North Dakota Work:

LIST MONTANA RESIDENT(S) WORKING SOLELY IN NORTH DAKOTA:

Worker(s) Name:

Worker(s) Permanent Address

Start Date and End Date or estimated dates

of Work Performed in ND:

__________________________________________________________________________________________________

I hereby certify that I have read and fully understand the accompanying instructions and have completed this form to the best

of my ability. All the information provided herein is true and correct.

Authorized Signature

Title

Date

Phone Number

__________________________________________________________________________________________________

Version July 1, 2015

Employment Verification Form Montana Employees Working Solely In North Dakota 2015

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