The Acord 130 form is a critical document used to apply for workers' compensation insurance. It collects essential information about the applicant's business, including operational details and employee classifications. Completing this form accurately is vital for obtaining the appropriate coverage for your workforce.
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WORKERS COMPENSATION APPLICATION
DATE (MM/DD/YYYY)
AGENCY NAME AND ADDRESS
COMPANY:
UNDERWRITER:
APPLICANT NAME:
OFFICE PHONE:
MOBILE PHONE:
MAILING ADDRESS (including ZIP + 4 or Canadian Postal Code)
YRS IN BUS:
SIC:
PRODUCER NAME:
NAICS:
CS REPRESENTATIVE
WEBSITE
NAME:
ADDRESS:
OFFICE PHONE
E-MAIL ADDRESS:
(A/C, No, Ext):
MOBILE
SOLE PROPRIETOR
CORPORATION
LLC
TRUST
UNINCORPORATED
PHONE:
ASSOCIATION
SUBCHAPTER
FAX
PARTNERSHIP
JOINT VENTURE
OTHER:
(A/C, No):
"S" CORP
E-MAIL
CREDIT
ID NUMBER:
BUREAU NAME:
CODE:
SUB CODE:
FEDERAL EMPLOYER ID NUMBER
NCCI RISK ID NUMBER
OTHER RATING BUREAU ID OR STATE
EMPLOYER REGISTRATION NUMBER
AGENCY CUSTOMER ID:
STATUS OF SUBMISSION
BILLING / AUDIT INFORMATION
QUOTE
ISSUE POLICY
BILLING PLAN
PAYMENT PLAN
AUDIT
BOUND (Give date and/or attach copy)
AGENCY BILL
ANNUAL
AT EXPIRATION
MONTHLY
ASSIGNED RISK (Attach ACORD 133)
DIRECT BILL
SEMI-ANNUAL
QUARTERLY
% DOWN:
LOCATIONS
LOC #
HIGHEST
STREET, CITY, COUNTY, STATE, ZIP CODE
FLOOR
POLICY INFORMATION
PROPOSED EFF DATE
PROPOSED EXP DATE
NORMAL ANNIVERSARY RATING DATE
PARTICIPATING
RETRO PLAN
NON-PARTICIPATING
PART 1 - WORKERS
PART 2 - EMPLOYER'S LIABILITY
PART 3 - OTHER
DEDUCTIBLES
AMOUNT / %
OTHER COVERAGES
(N / A in WI)
COMPENSATION (States)
STATES INS
$
EACH ACCIDENT
MEDICAL
U.S.L. & H.
MANAGED
CARE OPTION
DISEASE-POLICY LIMIT
INDEMNITY
VOLUNTARY
COMP
DISEASE-EACH EMPLOYEE
FOREIGN COV
DIVIDEND PLAN/SAFETY GROUP
ADDITIONAL COMPANY INFORMATION
SPECIFY ADDITIONAL COVERAGES / ENDORSEMENTS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
TOTAL ESTIMATED ANNUAL PREMIUM - ALL STATES
TOTAL ESTIMATED ANNUAL PREMIUM ALL STATES
TOTAL MINIMUM PREMIUM ALL STATES
TOTAL DEPOSIT PREMIUM ALL STATES
CONTACT INFORMATION
TYPE
NAME
MOBILE PHONE
INSPECTION
ACCTNG
RECORD
CLAIMS
INFO
INDIVIDUALS INCLUDED / EXCLUDED
PARTNERS, OFFICERS, RELATIVES ( Must be employed by business operations) TO BE INCLUDED OR EXCLUDED (Remuneration/Payroll to be included must be part of rating information section.) Exclusions in Missouri must meet the requirements of Section 287.090 RSMo.
STATE
DATE OF BIRTH
TITLE/
OWNER-
DUTIES
INC/EXC
CLASS CODE
REMUNERATION/PAYROLL
RELATIONSHIP
SHIP %
ACORD 130 (2013/01)
Page 1 of 4
© 1980-2013 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
STATE RATING SHEET #
OF
SHEETS
STATE RATING WORKSHEET
FOR MULTIPLE STATES, ATTACH AN ADDITIONAL PAGE 2 OF THIS FORM RATING INFORMATION - STATE:
LOC # CLASS CODE
DESCR
CODE
CATEGORIES, DUTIES, CLASSIFICATIONS
# EMPLOYEES
FULL PART
TIME TIME
SIC
NAICS
ESTIMATED ANNUAL
REMUNERATION/
PAYROLL
ESTIMATED
RATE ANNUAL MANUAL PREMIUM
PREMIUM
STATE:
FACTOR
FACTORED PREMIUM
TOTAL
N / A
INCREASED LIMITS
SCHEDULE RATING *
DEDUCTIBLE *
CCPAP
STANDARD PREMIUM
EXPERIENCE OR MERIT
PREMIUM DISCOUNT
MODIFICATION
EXPENSE CONSTANT
ASSIGNED RISK SURCHARGE *
TAXES / ASSESSMENTS *
ARAP *
* N / A in Wisconsin
TOTAL ESTIMATED ANNUAL PREMIUM
MINIMUM PREMIUM
DEPOSIT PREMIUM
REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Page 2 of 4
PRIOR CARRIER INFORMATION / LOSS HISTORY
PROVIDE INFORMATION FOR THE PAST 5 YEARS AND USE THE REMARKS SECTION FOR LOSS DETAILS
LOSS RUN ATTACHED
YEAR
CARRIER & POLICY NUMBER
ANNUAL PREMIUM
MOD
# CLAIMS
AMOUNT PAID
RESERVE
CO:
POL #:
NATURE OF BUSINESS / DESCRIPTION OF OPERATIONS
GIVE COMMENTS AND DESCRIPTIONS OF BUSINESS, OPERATIONS AND PRODUCTS: MANUFACTURING - RAW MATERIALS, PROCESSES, PRODUCT, EQUIPMENT; CONTRACTOR - TYPE OF WORK, SUB-CONTRACTS; MERCANTILE - MERCHANDISE, CUSTOMERS, DELIVERIES; SERVICE - TYPE, LOCATION; FARM - ACREAGE, ANIMALS, MACHINERY, SUB-CONTRACTS.
GENERAL INFORMATION
EXPLAIN ALL "YES" RESPONSES
1.DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT / WATERCRAFT?
2.DO / HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc)
3.ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET?
4.ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER?
5.IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS?
6.ARE SUB-CONTRACTORS USED? (If "YES", give % of work subcontracted)
7.ANY WORK SUBLET WITHOUT CERTIFICATES OF INSURANCE? (If "YES", payroll for this work must be included in the State Rating Worksheet on Page 2)
8.IS A WRITTEN SAFETY PROGRAM IN OPERATION?
9.ANY GROUP TRANSPORTATION PROVIDED?
10.ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE?
11.ANY SEASONAL EMPLOYEES?
12.IS THERE ANY VOLUNTEER OR DONATED LABOR? (If "YES", please specify)
13.ANY EMPLOYEES WITH PHYSICAL HANDICAPS?
14.DO EMPLOYEES TRAVEL OUT OF STATE? (If "YES", indicate state(s) of travel and frequency)
15.ARE ATHLETIC TEAMS SPONSORED?
Y / N
Page 3 of 4
GENERAL INFORMATION (continued)
16.ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE?
17.ANY OTHER INSURANCE WITH THIS INSURER?
18.ANY PRIOR COVERAGE DECLINED / CANCELLED / NON-RENEWED IN THE LAST THREE (3) YEARS? (Missouri Applicants - Do not answer this question)
19.ARE EMPLOYEE HEALTH PLANS PROVIDED?
20.DO ANY EMPLOYEES PERFORM WORK FOR OTHER BUSINESSES OR SUBSIDIARIES?
21.DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?
22.DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME? If "YES", # of Employees:
23.ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST FIVE (5) YEARS? (If "YES", please specify)
24.ANY UNDISPUTED AND UNPAID WORKERS COMPENSATION PREMIUM DUE FROM YOU OR ANY COMMONLY MANAGED OR OWNED ENTERPRISES? IF YES, EXPLAIN INCLUDING ENTITY NAME(S) AND POLICY NUMBER(S).
SIGNATURE
Copy of the Notice of Information Practices (Privacy) has been given to the applicant. (Not required in all states, contact your agent or broker for your state's requirements.)
PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES. YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE. THESE RIGHTS MAY BE LIMITED IN SOME STATES. PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION.
(Not applicable in AZ, CA, DE, KS, MA, MN, ND, NY, OR, VA, or WV. Specific ACORD 38s are available for applicants in these states.)
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects that person to criminal and civil penalties (In Oregon, the aforementioned actions may constitute a fraudulent insurance act which may be a crime and may subject the person to penalties). (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation). (Not applicable in AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PR, RI, TN, VA, VT, WA and WV).
Applicable in AL, AR, AZ, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines or confinement in prison.
Applicable in Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company, Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the department of regulatory agencies.
Applicable in Florida and Oklahoma: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (In FL, a person is guilty of a felony of the third degree).
Applicable in Kansas: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.
Applicable in Maine, Tennessee, Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Applicable in Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.
Applicable in Utah: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison.
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.
APPLICANT'S SIGNATURE (Must be Officer, Owner or Partner)
DATE
PRODUCER'S SIGNATURE
NATIONAL PRODUCER NUMBER
Page 4 of 4
The ACORD 125 form is similar to the ACORD 130 in that both serve as applications for insurance. The ACORD 125 is specifically designed for commercial general liability insurance, while the ACORD 130 focuses on workers' compensation. Both forms collect essential information about the applicant's business, including contact details, business structure, and insurance history. The ACORD 125, like the ACORD 130, requires the applicant to provide details about their operations and any specific risks associated with their business activities.
The ACORD 133 form is another document that parallels the ACORD 130. It is utilized for assigned risk workers' compensation insurance. While the ACORD 130 gathers general information about the applicant's workers' compensation needs, the ACORD 133 is specifically for those who may not qualify for standard coverage. Both forms require similar applicant information, including business structure and employee details, but the ACORD 133 focuses more on the unique circumstances that lead to an assigned risk designation.
The ACORD 101 form also shares similarities with the ACORD 130. The ACORD 101 is an additional remarks schedule that can be attached to various ACORD forms, including the ACORD 130. It allows applicants to provide further details or explanations that may be necessary for the insurance underwriter. Both forms aim to ensure that the insurer has a complete understanding of the applicant's situation, thus facilitating a more accurate assessment of risk and coverage needs.
In addition to various ACORD forms, understanding the nuances of notary acknowledgments is crucial for maintaining the integrity of legal processes. The California Notary Acknowledgment form is vital for verifying the signer's identity and signature, as it asserts that the signer willingly acknowledged their signature before a Notary Public. For those seeking more information on editable forms and notary processes, resources like https://californiapdf.com/ can be immensely valuable.
Lastly, the ACORD 140 form is related to the ACORD 130 as it is used for business auto insurance applications. While the ACORD 130 focuses on workers' compensation, the ACORD 140 addresses the specific insurance needs related to vehicles used for business purposes. Both forms require information about the business, including its structure and operational details, ensuring that the insurer has a comprehensive view of the applicant's risk profile.
Completing the ACORD 130 form requires attention to detail and accurate information. This form is essential for applying for workers' compensation insurance. Follow these steps carefully to ensure that all necessary information is provided correctly.
After completing the form, review all entries for accuracy. Make sure to attach any necessary documents, such as loss runs or additional remarks, before submitting the application to the insurance provider.
The ACORD 130 form is a vital document used in the application process for workers' compensation insurance. However, it is often accompanied by other forms and documents that provide additional information and context for the insurer. Here are five commonly used forms that complement the ACORD 130:
Each of these forms plays a significant role in the overall application process for workers' compensation insurance. Together, they provide insurers with a comprehensive view of the applicant's business, enabling them to make informed decisions regarding coverage and premiums.
Incomplete Contact Information: Failing to provide complete contact details can lead to communication issues. Make sure to include all relevant phone numbers and email addresses for both the applicant and the agency.
Incorrect Classification Codes: Using the wrong SIC or NAICS codes can affect the premium calculation. Ensure that the codes accurately reflect the nature of your business operations.
Omitting Employee Information: Not including all employees, especially those who should be excluded or included, can lead to incorrect payroll estimates. Be thorough in listing all individuals involved in the business.
Neglecting to Review Past Coverage: Forgetting to provide prior carrier information and loss history may raise red flags. Always include this information for the past five years to ensure transparency and accuracy.
When filling out the ACORD 130 form for workers' compensation, it's essential to approach the task with care. Here are ten important do's and don'ts to keep in mind:
By following these guidelines, you can help ensure a smoother application process for workers' compensation coverage.