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The Acord 130 form, a comprehensive and crucial document in the insurance industry, serves as the standard workers compensation application used across the United States to gather necessary information from businesses seeking to secure workers compensation coverage. This detailed form captures vital data ranging from basic business details, such as the applicant's name, mailing address, and contact information, to more intricate aspects including the type of business entity, years in business, industry classification codes (SIC and NAICS), and detailed employment information. It also addresses the nature of the business operations, specifics about locations where the business operates, and information about the work performed, which plays a pivotal role in assessing the risk and determining the insurance premium. Additionally, the form inquires about the use of subcontractors, safety programs, seasonal employees, and any work performed that involves special risks, such as working at heights or handling hazardous materials. The various sections dedicated to policy information, billing, prior carrier information, and loss history provide insurers with a comprehensive view of the applicant’s business and its insurance needs, facilitating a more accurate and tailored insurance offering. Understanding the Acord 130 form is essential for businesses and insurance professionals alike, as it is the foundational step in obtaining workers compensation insurance, a critical component of business risk management.

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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:

 

 

 

ADDRESS:

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

SEMI-ANNUAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUARTERLY

 

 

% DOWN:

 

 

 

 

 

 

 

QUARTERLY

 

 

 

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

 

 

 

 

 

(N / A in WI)

 

 

 

 

 

 

 

 

 

$

 

 

 

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

OFFICE PHONE

MOBILE PHONE

E-MAIL

 

 

 

 

 

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

LOC #

NAME

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

AGENCY CUSTOMER ID:

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

 

FACTOR

FACTORED PREMIUM

TOTAL

N / A

$

 

 

$

INCREASED LIMITS

 

$

SCHEDULE RATING *

 

$

DEDUCTIBLE *

 

$

CCPAP

 

$

 

 

$

STANDARD PREMIUM

 

$

EXPERIENCE OR MERIT

 

$

PREMIUM DISCOUNT

 

$

MODIFICATION

 

 

 

 

$

EXPENSE CONSTANT

N / A

$

ASSIGNED RISK SURCHARGE *

 

$

TAXES / ASSESSMENTS *

N / A

$

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)

 

 

ACORD 130 (2013/01)

Page 2 of 4

PRIOR CARRIER INFORMATION / LOSS HISTORY

AGENCY CUSTOMER ID:

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 #:

 

 

 

 

 

 

 

CO:

 

 

 

 

 

 

 

POL #:

 

 

 

 

 

 

 

CO:

 

 

 

 

 

 

 

POL #:

 

 

 

 

 

 

 

CO:

 

 

 

 

 

 

 

POL #:

 

 

 

 

 

 

 

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

ACORD 130 (2013/01)

Page 3 of 4

(Applicant's Initials):

GENERAL INFORMATION (continued)

AGENCY CUSTOMER ID:

EXPLAIN ALL "YES" RESPONSES

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).

Y / N

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

ACORD 130 (2013/01)

Page 4 of 4

File Characteristics

Fact Name Description
Form Purpose The Acord 130 form is used for applying for Workers’ Compensation Insurance.
Date Format The application date must be entered in the format MM/DD/YYYY.
Applicant Information Includes details such as applicant name, contact information, and business structure (e.g., Sole Proprietor, Corporation).
Business Information Requires specifics about the business, including years in business, standard industrial classification (SIC) and North American Industry Classification System (NAICS) codes.
Rating Information For businesses operating in multiple states, additional state-specific rating sheets may be attached.
Loss History Applicants must provide prior carrier information and loss history for the past five years.
Agent Information Details of the agency or agent handling the application, including name and contact information.
Signature and Compliance The form requires the applicant's and producer’s signatures to certify the accuracy of the provided information and includes fraud warnings applicable in various states.

Steps to Writing Acord 130

Filling out the Acord 130 form is an important step in applying for workers' compensation insurance. This document is thorough and requires precise information about your business, its operations, coverage needs, and personnel details. Ensuring accuracy and completeness when completing this form is crucial to accurately assess your insurance needs and provide the right coverage for your employees. Follow these steps carefully to complete the form.

  1. Enter the application date in the format MM/DD/YYYY at the top of the form.
  2. Fill in the agency name and address, company, and underwriter information in the provided fields.
  3. Provide the applicant's full name, office and mobile phone numbers, and mailing address, including the ZIP+4 or Canadian Postal Code.
  4. Specify the number of years in business (YRS IN BUS), Standard Industrial Classification (SIC) code, North American Industry Classification System (NAICS) code, and the producer and consumer services (CS) representative's name and contact information.
  5. Select the legal status of your organization (e.g., sole proprietor, corporation, LLC, etc.) and provide the applicable identification numbers like the Credit ID number, NCCI Risk ID number, other rating bureau ID, and Federal Employer ID number.
  6. Complete the 'Status of Submission' section, including billing and audit information. Choose the appropriate billing plan and payment plan, indicating if the submission is a quote, issue, bound policy, etc.
  7. Under 'Locations,' list the location number and the highest floor for each business location, including street, city, county, state, and zip code.
  8. Fill in the proposed effective and expiration dates, the normal anniversary rating date, and select if the policy has a retro plan or is participating/non-participating in dividend plans or safety groups.
  9. Specify the coverages needed in parts 1, 2, and 3 for Workers Compensation, Employer's Liability, and other deductibles or coverages.
  10. Provide details for additional coverages or endorsements required for your business.
  11. Estimate the annual premium for all states and insert the total minimum and deposit premium amounts.
  12. Enter contact information for individuals responsible for inspections, accounting, records, claims, and provide detailed information about partners, officers, and relatives involved in the business, specifying if they are to be included or excluded from coverage.
  13. Complete the state rating worksheet section for each state in which you operate, if applicable.
  14. Provide prior carrier information and loss history for the past five years.
  15. Describe your business operations in detail, including information about the nature of business and any special operations or materials handled.
  16. Answer general information questions truthfully, providing explanations for any "Yes" responses.
  17. Review the notice regarding personal information and the warning about fraudulent insurance acts at the bottom of the form. Sign the application, ensuring an authorized representative completes this section.

Once the form is filled out completely and accurately, review it carefully to ensure no detail is missed. This form provides essential information to your insurance underwriter, who will use it to evaluate your coverage needs accurately. After submission, an underwriter may contact you for further details or clarification before issuing a quote or policy. It is vital to respond promptly to any inquiries to expedite your application's processing.

Important Details about Acord 130

What is the Acord 130 form used for?

The Acord 130 form is an application for workers' compensation insurance. It is used by businesses to apply for coverage that provides benefits to employees in case of job-related injuries or diseases. This form collects detailed information about the business, its operations, and its employees to assess the risk and determine the premium for the insurance policy.

Who needs to fill out the Acord 130 form?

Any business that needs to obtain or renew workers' compensation insurance may need to fill out the Acord 130 form. This includes businesses of various types and sizes, from sole proprietorships to large corporations, across different industries. The form is typically filled out by the business owner, an authorized representative, or an insurance agent on behalf of the business.

What information is required on the Acord 130 form?

The Acord 130 form requires a range of information, including the business name, mailing address, years in business, nature of the business, federal employer ID number, details about locations, policy information, estimated annual premiums, and contact information for inspections, accounting records, and claims information. It also asks for details about any partners, officers, or relatives to be included or excluded from the policy, and prior carrier information and loss history.

How is the Acord 130 form used in the insurance underwriting process?

Insurance companies use the Acord 130 form as part of the underwriting process to evaluate the risk associated with insuring a particular business. The information provided on the form helps insurers to understand the business's operations, the potential for claims, and to calculate the appropriate premium for the coverage sought. This risk assessment is crucial in deciding whether to issue a policy and at what cost.

Can the Acord 130 form be submitted electronically?

Yes, the Acord 130 form can be submitted electronically in many cases. Many insurance companies and brokers accept electronic submissions, which can speed up the process of applying for or renewing workers' compensation insurance. Businesses should check with their insurance agent or insurer to verify if electronic submission is available and preferred.

Is there a fee to submit the Acord 130 form?

Generally, there is no fee to submit the Acord 130 form itself. However, upon acceptance of the application and issuance of a policy, the business will be responsible for paying the insurance premium as determined by the insurer based on the information provided in the form. Premiums vary widely depending on factors such as the size of the business, industry risk, and loss history.

What should a business do if they have questions about filling out the Acord 130 form?

If a business has questions about how to properly fill out the Acord 130 form, they should contact their insurance agent or broker for guidance. Insurance professionals are equipped to assist businesses in understanding and completing the form correctly, ensuring that all relevant information is provided to the insurer for an accurate risk assessment and premium calculation.

What if a business needs to make changes to information previously submitted on an Acord 130 form?

If a business needs to update or change information after submitting an Acord 130 form, they should immediately contact their insurance agent or insurer. Corrections or updates may affect the insurance coverage and premium, so it's important to provide accurate and current information as soon as possible.

Common mistakes

When completing the Acord 130 form, which is essential for workers' compensation insurance applications, several common mistakes can lead to delays or complications in obtaining coverage. Being aware of these errors and avoiding them can streamline the process and ensure accurate policy issuance.

One frequent oversight is failing to provide complete details in the applicant name and contact information sections. It's crucial that the applicant's full legal name, mailing address, and contact numbers are accurately entered. This information is not just for correspondence; it forms the basis of the legal contract between the insurer and the insured.

Another issue arises with incorrectly categorizing the business entity type. Choosing the wrong type, such as marking 'Sole Proprietor' instead of 'LLC,' can affect the rights and liabilities covered under the policy. Each entity type has specific legal definitions and insurance requirements, making this selection more than just a formality.

Providing inaccurate details in the years in business and business description sections can also lead to problems. Insurers use this information to assess risk levels. Misrepresentation, whether intentional or accidental, can lead to incorrect policy terms or even refusal of claims in the future.

Misunderstanding the state rating and classification codes is another common mistake. These classifications help determine premium levels based on the nature of work and associated risks. Incorrect codes may result in underinsuring, overinsuring, or even voiding coverage.

The total estimated annual premium section often contains inaccuracies due to incorrect payroll estimations or not accounting for all states of operation. These mistakes can significantly alter the premium calculations, affecting the cost of the policy.

Omitting or inaccurately reporting past claims history, under the prior carrier information/loss history section, is a critical error. This history helps insurers predict future risks and determine premiums. Failure to disclose or incorrect reporting can be seen as fraudulent.

Not fully understanding the billing/audit information section can lead to surprises in billing and audits. It's important to select the correct billing plan and understand how and when audits will be conducted.

Finally, neglecting to carefully review the entire form before submission, including the declarations and signatures at the end, is a widespread issue. This can lead to omissions and inaccuracies, potentially invalidating the application or delaying the underwriting process. It’s essential that all information provided is accurate to the best of the applicant's knowledge and that it is thoroughly checked before submission.

Documents used along the form

When applying for workers' compensation insurance, the Acord 130 form is foundational, but it's often not the only document needed in the submission process. Understanding the other forms and documents that may accompany an Acord 130 can streamline the application experience and ensure that all pertinent information is provided to the insurer.

  • Acord 125 (Commercial Insurance Application): This form collects general information about the business and the insurance coverage being sought. It's used for a broad range of commercial insurance applications, including liability, property, and auto, but can also be relevant when providing context alongside a workers' compensation application.
  • Acord 133 (Workers Compensation Insurance Plan Assigned Risk Section): When a business is unable to obtain workers' compensation insurance through the voluntary market due to a high-risk profile, the Acord 133 form is used to apply for coverage through the assigned risk plan. This form complements the Acord 130 by providing additional details required for the assigned risk pool.
  • Acord 137 (State-Specific Commercial Auto): If a business uses vehicles in its operations, this state-specific form provides information regarding commercial auto insurance. It may be necessary to accompany the Acord 130 when vehicle use relates to the employment practices of the company.
  • Loss Runs: While not a standardized form like the Acord documents, a Loss Run report from previous insurers shows the history of claims made by a business. Insurers often request this document to assess the risk and determine premiums for new applicants. It provides a detailed look at the past safety and financial impact of workers' compensation claims.

Each of these documents plays a crucial role in painting a comprehensive picture of the business applying for workers' compensation insurance. By providing detailed and accurate information across these forms, businesses can facilitate the underwriting process and secure the insurance necessary to protect themselves and their employees.

Similar forms

The Acord 130 form is closely similar to the Acord 125, Commercial Insurance Application. Both serve as comprehensive applications designed to collect detailed business information for insurance purposes. The Acord 125 also gathers general applicant information, business details, and insurance history, much like the Acord 130, which collects employer details for workers' compensation insurance. The key difference lies in their focus – while the Acord 130 is tailored specifically for workers' compensation, the Acord 125 is broader, covering various commercial insurance needs.

The General Liability Application, often a separate document tailored to businesses seeking liability coverage, shares similarities with the Acord 130 form in its structure and purpose. It collects data on the applicant’s business operations, much like the Acord 130, to evaluate risk and tailor liability coverage. Where the Acord 130 focuses on workers' compensation, the General Liability Application zeroes in on liability aspects, assessing potential risks from the company's operations that might lead to third-party claims.

Another similar document is the Business Owners Policy (BOP) Application. This application is designed for small to medium-sized businesses, combining property and liability insurance into one package. Like the Acord 130, which assesses risks for workers' compensation, the BOP application gathers detailed information about the business to determine the proper coverage levels needed for both property and general liability insurance, ensuring comprehensive protection against a range of business risks.

The Commercial Auto Application is used by businesses to secure coverage for vehicles used in their operations. Similar to the Acord 130 form, it requires detailed information about the business and its use of vehicles, intending to assess risk and determine appropriate coverage. Both applications serve as critical tools for insurers to gather necessary data to evaluate insurance needs accurately, albeit for different types of coverage – the Acord 130 for workers' compensation and the Commercial Auto Application for vehicle insurance.

The Umbrella Policy Application, which businesses use to obtain additional liability coverage beyond primary policy limits, also shares similarities with the Acord 130. Both documents play pivotal roles in the underwriting process, where detailed information collected helps insurers understand the full scope of the business's operations and potential risks, thereby offering an extra layer of protection on top of existing policies.

The Directors and Officers Liability Application is designed to protect company executives from personal losses due to their management actions. Although its coverage is quite different, the application process is similar to that of the Acord 130, as it involves detailed disclosure of the business activities, financial health, and risk exposures to ascertain the level of coverage needed.

The Professional Liability Insurance Application, needed by businesses to cover services-related risks, like negligence claims against professional advice or services rendered, aligns with the Acord 130 in its functionality. Both forms require in-depth business information to evaluate and mitigate specific risks associated with the professional services sector, contrasting with the Acord 130's focus on employee-related injuries.

Lastly, the Workers' Compensation Exemption Form, which is used by some business owners or contractors to exempt themselves from workers' compensation insurance, contrasts with the Acord 130’s purpose but is related in context. While it doesn’t collect business operation details extensively, it directly relates to workers' compensation insurance by identifying those who choose not to participate or are eligible for exemption, showcasing the varied needs and regulations within workers' compensation insurance.

Dos and Don'ts

When filling out the ACORD 130 form, which is widely used for workers' compensation applications, there are several best practices to follow, as well as common pitfalls to avoid. Ensuring accuracy and thoroughness in completing this document is critical for the successful processing of your application. Below are four tips on what you should and shouldn't do.

What You Should Do:

  1. Review all sections before starting: Before filling out the form, take the time to review each section to understand the information required. This preparation helps in gathering all necessary details beforehand, making the process smoother.
  2. Provide accurate and complete information: Ensure all data, from the business name to the federal employer ID number and the descriptions of operations, are accurate and thoroughly detailed. Accuracy is key to avoid any delays or issues with the application process.
  3. Include all relevant additional coverages: If your business needs specific endorsements or has unique risks, make sure to attach ACORD 101, Additional Remarks Schedule, or any other necessary documentation to clearly communicate these needs.
  4. Confirm the inclusion or exclusion of officers and partners: Clearly indicate whether partners, officers, and any relatives engaged in the business operations are to be included or excluded from the coverage, along with their respective remuneration/payroll information.

What You Shouldn't Do:

  1. Avoid leaving sections incomplete: Do not skip any sections or leave blanks unless a section truly does not apply to your situation. Incomplete forms can lead to unnecessary back-and-forth communication, delaying the application's processing.
  2. Don't guess on financial figures: Ensure that all financial information, such as estimated annual premiums and remuneration/payroll, is based on the most current and accurate data available. Guessing can lead to incorrect premium calculations and coverage issues.
  3. Refrain from ignoring the loss history: The prior carrier information and loss history section is crucial. Not disclosing past losses can be seen as misleading and may affect your coverage and premium.
  4. Avoid submitting outdated information: Double-check that all the information, especially contact details and business operations descriptions, is current. Changes in your business might not be reflected if relying on old data, leading to discrepancies in your application.

Misconceptions

Understanding the Acord 130 form is crucial for businesses seeking workers' compensation insurance. However, there are common misconceptions that can lead to confusion and incorrect use of this form. Let's clarify some of these misunderstandings to ensure users can fill out the form accurately and effectively.

  • Only for large businesses: Some believe that the Acord 130 form is only relevant for large corporations. However, this form is essential for businesses of all sizes seeking workers' compensation coverage. It collects the necessary information to assess risks and determine premiums for businesses of various scales.

  • Complex and time-consuming: The perception that filling out the Acord 130 form is complicated and time-consuming might deter some from completing it. While it is comprehensive, its purpose is to gather accurate and relevant information about your business operations, which is crucial for obtaining the right insurance coverage.

  • One-time submission: It's a common misconception that once submitted, the Acord 130 form does not need updating. Businesses evolve, and so do their insurance needs. Updating this form can help ensure that coverage reflects current business operations and risks.

  • Personal information is not important: Every section, including personal information of the owners or key employees, is vital. This data can influence the risk assessment and premium calculation, and omitting it can lead to inaccuracies in your coverage.

  • Only the business owner can fill it out: While it's crucial that the information is accurate and complete, anyone with comprehensive knowledge of the business operations and authority can complete the form. It’s often a collaborative effort involving multiple departments.

  • Details about business operations are irrelevant: The detailed description of your business operations is one of the most critical pieces of information on the Acord 130 form. It allows insurers to fully understand your business and customize your coverage accordingly.

  • It's solely for workers' compensation insurance: Though primarily used for workers' compensation applications, information from the Acord 130 can also be helpful in applying for other types of business insurance. It provides a comprehensive overview that can expedite other insurance applications.

  • Privacy is compromised: Concerns about providing sensitive information are understandable. However, the data collected is used strictly for insurance purposes under stringent privacy laws and regulations to protect your information.

  • No need to review before submitting: Reviewing the completed form is crucial. Ensuring accuracy and completeness can prevent delays in processing and help avoid issues with coverage. It’s beneficial to have another set of eyes review the form if possible.

By demystifying these misconceptions, businesses can approach the Acord 130 form with confidence, understanding its importance in securing the right workers' compensation coverage. Remember, accurate and thorough information is key to obtaining optimal insurance coverage for your business.

Key takeaways

Filling out the Acord 130 form, which is the Workers Compensation Application, is a critical step for businesses seeking to ensure their employees are covered in case of work-related injuries or illnesses. Here are five key takeaways to consider when completing and using this form:

  • Every section of the Acord 130 form must be filled out accurately and completely to ensure that the workers' compensation insurance policy reflects the true nature of the business operations, the number of employees, and other crucial information. This accuracy is vital for determining the right premium and coverage options.
  • The form asks for detailed information about the applicant's business, including the type of business entity, years in operation, and details about the locations where business is conducted. This information helps insurance companies assess the risk associated with the business.
  • Employers have the option to include or exclude certain individuals from coverage, such as partners, officers, and relatives. Decisions on inclusion or exclusion should be made carefully, considering the implications for both the employer and the employees.
  • Risk identification numbers, such as the Federal Employer ID Number (FEIN) and others, are required. These identifiers are used to track the employer's compliance and history with workers' compensation claims, which can affect insurance rates and eligibility.
  • Billing and audit information specify how the employer prefers to be billed and how audits will be conducted to verify the accuracy of the payroll and class codes reported at the beginning of the policy period. Choosing the right plans can impact the business's cash flow and compliance with the policy terms.

Understanding and meticulously completing the Acord 130 form is crucial for securing workers' compensation insurance that is both compliant with state laws and tailored to the specific needs of the business and its employees. Employers should consult with a qualified insurance agent to ensure that all information is accurate and that their coverage meets all legal requirements.

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