"Employment Verification Form - Montana Employees Working Solely in North Dakota" - Montana

Employment Verification Form - Montana Employees Working Solely in North Dakota is a legal document that was released by the Montana Department of Labor and Industry - a government authority operating within Montana.

Form Details:

  • Released on July 1, 2015;
  • The latest edition currently provided by the Montana Department of Labor and Industry;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Montana Department of Labor and Industry.

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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
 
 
 
 
 
 
 
 
 
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